Provider Demographics
NPI:1629047055
Name:JETER, TRACEY MECHELLE (RN)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:MECHELLE
Last Name:JETER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7010 N 55TH ST
Mailing Address - Street 2:APT. G
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-6349
Mailing Address - Country:US
Mailing Address - Phone:414-760-0817
Mailing Address - Fax:414-760-0835
Practice Address - Street 1:7010 N 55TH ST
Practice Address - Street 2:APT. G
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-6349
Practice Address - Country:US
Practice Address - Phone:414-760-0817
Practice Address - Fax:414-760-0835
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39926000Medicaid