Provider Demographics
NPI:1851924237
Name:JETER SPEECH LANGUAGE PATHOLOGY SERVICES, LLC
Entity Type:Organization
Organization Name:JETER SPEECH LANGUAGE PATHOLOGY SERVICES, LLC
Other - Org Name:JETER THERAPY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MCD/CCC-SLP
Authorized Official - Phone:337-718-3404
Mailing Address - Street 1:1950 E 70TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5345
Mailing Address - Country:US
Mailing Address - Phone:318-219-6064
Mailing Address - Fax:
Practice Address - Street 1:1950 E 70TH ST STE A
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5345
Practice Address - Country:US
Practice Address - Phone:318-219-6064
Practice Address - Fax:318-225-7928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-13
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA6710OtherLA LICENSE
LA6710OtherLICENSE