Provider Demographics
NPI:1124165931
Name:JETER, JAMAL P (DPM)
Entity type:Individual
Prefix:
First Name:JAMAL
Middle Name:P
Last Name:JETER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30915 LORAIN RD
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-4722
Mailing Address - Country:US
Mailing Address - Phone:440-471-4970
Mailing Address - Fax:440-617-6065
Practice Address - Street 1:30915 LORAIN RD STE 114
Practice Address - Street 2:
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070-4722
Practice Address - Country:US
Practice Address - Phone:440-471-4970
Practice Address - Fax:440-617-6065
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-003234213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2220206Medicaid
U81761Medicare UPIN
OH4032223Medicare PIN