MEDICARE: MS. TRACEY MECHELLE JETER RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse		WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629047055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TRACEY MECHELLE JETER RN

Provider Business Mailing Address
First Line	:	7010 N 55TH ST
Second Line	:	APT. G
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-6349
Country	:	US
Telephone Number	:	414-760-0817
Fax Number	:	414-760-0835

Provider Business Practice Location Address
First Line	:	7010 N 55TH ST
Second Line	:	APT. G
City	:	MILWAUKEE
State	:	WI
Zip	:	53223-6349
Country	:	US
Telephone Number	:	414-760-0817
Fax Number	:	414-760-0835

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	07/09/2007

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