Provider Demographics
NPI:1487100194
Name:JETER, DWAYNE SR
Entity type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:JETER
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 104
Mailing Address - Street 2:
Mailing Address - City:ELYSIAN FIELDS
Mailing Address - State:TX
Mailing Address - Zip Code:75642-0104
Mailing Address - Country:US
Mailing Address - Phone:903-503-3111
Mailing Address - Fax:
Practice Address - Street 1:7505 PINES RD STE 1200I
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-3900
Practice Address - Country:US
Practice Address - Phone:318-716-1707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health