Provider Demographics
NPI:1841011970
Name:JETER, SYDNEY KATE
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:KATE
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 1:18301 LYNN RD
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33917-4767
Mailing Address - Country:US
Mailing Address - Phone:239-471-8579
Mailing Address - Fax:
Practice Address - Street 1:12493 BRANTLEY COMMONS CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5693
Practice Address - Country:US
Practice Address - Phone:239-268-8707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-382044106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician