Provider Demographics
NPI:1851392583
Name:JETER JOHNSON, MONICA L (PHD)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:L
Last Name:JETER JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 BRYAN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-8103
Mailing Address - Country:US
Mailing Address - Phone:214-828-2603
Mailing Address - Fax:214-828-4954
Practice Address - Street 1:5501 BRYAN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-8103
Practice Address - Country:US
Practice Address - Phone:214-828-2603
Practice Address - Fax:214-828-4954
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3-0561103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B3446Medicare ID - Type Unspecified