Provider Demographics
NPI:1497261598
Name:ERNEST JETER, MSED
Entity Type:Organization
Organization Name:ERNEST JETER, MSED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:
Authorized Official - Last Name:JETER
Authorized Official - Suffix:
Authorized Official - Credentials:MSED
Authorized Official - Phone:347-596-7357
Mailing Address - Street 1:1640 JOHNSON RD APT 114B
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-1258
Mailing Address - Country:US
Mailing Address - Phone:347-596-7357
Mailing Address - Fax:804-479-3373
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-27
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency