Provider Demographics
NPI:1013253905
Name:JETER, JUSTINE BRI (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTINE
Middle Name:BRI
Last Name:JETER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S MAIN ST
Mailing Address - Street 2:TRINITY SPRINGS PAVILION
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4917
Mailing Address - Country:US
Mailing Address - Phone:817-702-3321
Mailing Address - Fax:
Practice Address - Street 1:1350 S MAIN ST STE 1600
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7663
Practice Address - Country:US
Practice Address - Phone:817-702-1670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16399-40183500000X
TX50312183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist