Provider Demographics
NPI:1407355977
Name:JETER, SHAWN DARRELL
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:DARRELL
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 1:2817 WELLESLEY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43209-3007
Mailing Address - Country:US
Mailing Address - Phone:614-975-7633
Mailing Address - Fax:
Practice Address - Street 1:2817 WELLESLEY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43209-3007
Practice Address - Country:US
Practice Address - Phone:614-975-7633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator