Provider Demographics
NPI:1790484145
Name:JETER, JOSEPHINE GIBSON
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:GIBSON
Last Name:JETER
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 1:999 E BASELINE RD APT 3105
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1307
Mailing Address - Country:US
Mailing Address - Phone:520-788-0263
Mailing Address - Fax:
Practice Address - Street 1:8225 S 59TH AVE
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2886
Practice Address - Country:US
Practice Address - Phone:602-764-9016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP031966164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse