Provider Demographics
NPI:1598706749
Name:JETSON, DAVID (LPC - MH)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:JETSON
Suffix:
Gender:M
Credentials:LPC - MH
Other - Prefix:
Other - First Name:DAVE
Other - Middle Name:
Other - Last Name:JETSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC - MH
Mailing Address - Street 1:1301 WEST OMAHA ST.
Mailing Address - Street 2:SUITE 220
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-4694
Mailing Address - Country:US
Mailing Address - Phone:605-718-5500
Mailing Address - Fax:605-716-0415
Practice Address - Street 1:636 SAINT ANNE ST
Practice Address - Street 2:SUITE 202
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4694
Practice Address - Country:US
Practice Address - Phone:605-718-5500
Practice Address - Fax:605-716-9944
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDLPC-MH2145101Y00000X, 101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional