Provider Demographics
NPI:1104361534
Name:JETER, TODD B (LCSW, CADC III)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:B
Last Name:JETER
Suffix:
Gender:M
Credentials:LCSW, CADC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 W 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-3955
Mailing Address - Country:US
Mailing Address - Phone:541-234-3090
Mailing Address - Fax:541-735-9480
Practice Address - Street 1:1355 W 13TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3955
Practice Address - Country:US
Practice Address - Phone:541-234-3090
Practice Address - Fax:541-735-9480
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL104271041C0700X
OR16-11-18101YA0400X
OR19-01-20101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500725923Medicaid
OR500731705Medicaid