Provider Demographics
NPI:1942736970
Name:JETER, ALLEN (MA, LAT, ATC)
Entity type:Individual
Prefix:MR
First Name:ALLEN
Middle Name:
Last Name:JETER
Suffix:
Gender:M
Credentials:MA, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 RAMSEY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-1420
Mailing Address - Country:US
Mailing Address - Phone:910-630-7596
Mailing Address - Fax:910-630-7599
Practice Address - Street 1:5400 RAMSEY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28311-1420
Practice Address - Country:US
Practice Address - Phone:910-630-7596
Practice Address - Fax:910-630-7599
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-35992255A2300X
ARAT 5352255A2300X
KS24-009072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer