Individual
DWAYNE JETER SR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
7505 PINES RD STE 1200I, SHREVEPORT, LA 71129-3900
(318) 716-1707
Mailing address
PO BOX 104, ELYSIAN FIELDS, TX 75642-0104
(903) 503-3111
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
—
—
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Enumeration date
09/01/2016
Last updated
12/05/2018
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