Provider Demographics
NPI:1144402918
Name:JETER, RICHARD GRANT (BA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:GRANT
Last Name:JETER
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1012
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98291-1012
Mailing Address - Country:US
Mailing Address - Phone:360-722-1532
Mailing Address - Fax:
Practice Address - Street 1:3322 BROADWAY
Practice Address - Street 2:1ST FLOOR
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4425
Practice Address - Country:US
Practice Address - Phone:424-349-6800
Practice Address - Fax:425-349-6805
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00010692101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health