Provider Demographics
NPI:1023066909
Name:JETER, MARK EDWARD (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:JETER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 CAPE CORAL PKWY, W
Mailing Address - Street 2:SUITE #105
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914
Mailing Address - Country:US
Mailing Address - Phone:239-549-2225
Mailing Address - Fax:239-549-2265
Practice Address - Street 1:615 CAPE CORAL PKWY W
Practice Address - Street 2:SUITE #105
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33914-6593
Practice Address - Country:US
Practice Address - Phone:239-549-2225
Practice Address - Fax:239-549-2265
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006411111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22758Medicare ID - Type Unspecified