Provider Demographics
NPI:1710941703
Name:JETER, LORI S (PT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:S
Last Name:JETER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 VERNON ROAD
Mailing Address - Street 2:STUITE A
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-3871
Mailing Address - Country:US
Mailing Address - Phone:706-845-9383
Mailing Address - Fax:706-845-9482
Practice Address - Street 1:1805 VERNON ROAD
Practice Address - Street 2:STUITE A
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-3871
Practice Address - Country:US
Practice Address - Phone:706-845-9383
Practice Address - Fax:706-845-9482
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002298225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000564561CMedicaid