Provider Demographics
NPI:1013710490
Name:JETER, CRESCENT SHUBRADA
Entity type:Individual
Prefix:
First Name:CRESCENT
Middle Name:SHUBRADA
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 1:304 TULIP TREE LN
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29680-7352
Mailing Address - Country:US
Mailing Address - Phone:864-787-9180
Mailing Address - Fax:
Practice Address - Street 1:102 COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:SC
Practice Address - Zip Code:29673-7766
Practice Address - Country:US
Practice Address - Phone:864-520-8152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17691101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health