Provider Demographics
NPI:1760118293
Name:JETTER, HOLLY
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:
Last Name:JETTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8183 COPPERAS HILL DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-8935
Mailing Address - Country:US
Mailing Address - Phone:843-814-6959
Mailing Address - Fax:
Practice Address - Street 1:159 CIVITAS ST STE 205
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-2201
Practice Address - Country:US
Practice Address - Phone:843-814-6959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8090101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional