Provider Demographics
NPI:1740480342
Name:CARTER, JEANETTE (NP)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:CARTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1839 S EL DORADO ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-2025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1839 S EL DORADO ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206-2025
Practice Address - Country:US
Practice Address - Phone:209-463-0872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 494052363L00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1104982495OtherMEDI-CAL
CA1114083771OtherMEDI-CAL
CANP7506OtherNURSE PRACTITIONER LICENS
CA1659436095OtherMEDI-CAL