Provider Demographics
NPI:1134121858
Name:JETER, JEFFREY S (PT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:S
Last Name:JETER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 E ENTERPRISE AVE # 113
Mailing Address - Street 2:ADVANCED PHYSICAL THERAPY
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-991-2561
Mailing Address - Fax:920-991-2563
Practice Address - Street 1:2105 E ENTERPRISE AVE # 113
Practice Address - Street 2:ADVANCED PHYSICAL THERAPY
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7862
Practice Address - Country:US
Practice Address - Phone:920-991-2561
Practice Address - Fax:920-991-2563
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4557225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40357800Medicaid
WI40357800Medicaid
000486443Medicare ID - Type Unspecified
WI5567490001Medicare NSC