Provider Demographics
NPI:1710381314
Name:JETER, ALLEN (DD,MAC,CDDC)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:
Last Name:JETER
Suffix:
Gender:M
Credentials:DD,MAC,CDDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2942 N 24TH ST
Mailing Address - Street 2:114-766
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7844
Mailing Address - Country:US
Mailing Address - Phone:480-521-4815
Mailing Address - Fax:623-242-7910
Practice Address - Street 1:2942 N 24TH ST
Practice Address - Street 2:114-766
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7844
Practice Address - Country:US
Practice Address - Phone:480-521-4815
Practice Address - Fax:602-424-5757
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-10
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA86520101YA0400X
PA101YM0800X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral