Provider Demographics
NPI:1760677074
Name:JETER, SUSAN B
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:B
Last Name:JETER
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:B
Other - Last Name:JETER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS,LPE
Mailing Address - Street 1:2200 LIVE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-9340
Mailing Address - Country:US
Mailing Address - Phone:501-246-5308
Mailing Address - Fax:
Practice Address - Street 1:10618 BRECKENRIDGE DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-1802
Practice Address - Country:US
Practice Address - Phone:501-217-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR97-05E235500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR97-05EOtherSTATE OF ARKANSAS