Doctor Name: | NICHOLE JETERS |
NPI Number: | 1174770648 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | LCPC |
License Number: | 180.009521 |
Business Practice Address: | 4241 Hwy 14 W Christopher, IL - 628221037 |
Business Phone Number: | 6187242401 |
Business Fax Number: | 6187244628 |
Mailing Address: | 4241 Hwy 14 W, CHRISTOPHER |
State: | IL |
Postal Code: | 628221037 |
Phone Number: | 6187242401 |
Fax Number: | 6187244628 |
NPI Enumeration Date: | 08/26/2008 |
NPI Last Update Date: | 11/20/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | 180.009521 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IL |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |