Provider Demographics
NPI:1750742201
Name:JETER, ROSE R (LCSW)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:R
Last Name:JETER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S SYCAMORE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-4279
Mailing Address - Country:US
Mailing Address - Phone:804-835-9511
Mailing Address - Fax:804-479-3373
Practice Address - Street 1:115 S SYCAMORE ST
Practice Address - Street 2:SUITE B
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-4279
Practice Address - Country:US
Practice Address - Phone:804-835-9511
Practice Address - Fax:804-479-3373
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-11
Last Update Date:2016-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040091251041C0700X
NY0834281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical