Provider Demographics
NPI:1235477514
Name:JETER, MYCA (MSW, LCSWA)
Entity Type:Individual
Prefix:
First Name:MYCA
Middle Name:
Last Name:JETER
Suffix:
Gender:F
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 KINNAKEET DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-5194
Mailing Address - Country:US
Mailing Address - Phone:919-672-9807
Mailing Address - Fax:
Practice Address - Street 1:318 KINNAKEET DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-5194
Practice Address - Country:US
Practice Address - Phone:919-672-9807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-22
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0150321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical