Provider Demographics
NPI:1932989472
Name:JETER, KENDALL
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:
Last Name:JETER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:154 FRANKLIN DR
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:TN
Mailing Address - Zip Code:37307-3608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3510 E SHIELDS AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-6909
Practice Address - Country:US
Practice Address - Phone:559-222-4807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7726225X00000X
CA25517225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist