Provider Demographics
NPI:1295185577
Name:JETER, ERNEST
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:JETER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 JOHNSON RD
Mailing Address - Street 2:SUITE 114B
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-1272
Mailing Address - Country:US
Mailing Address - Phone:347-596-7357
Mailing Address - Fax:
Practice Address - Street 1:115 S SYCAMORE ST STE B
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-4279
Practice Address - Country:US
Practice Address - Phone:347-596-7357
Practice Address - Fax:804-479-3373
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-0605341101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool