Provider Demographics
NPI:1194147462
Name:JETER, CHRISTINA DENISE (COTA/L)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:DENISE
Last Name:JETER
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 E MOUNTAIN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORS
Mailing Address - State:SC
Mailing Address - Zip Code:29687-6416
Mailing Address - Country:US
Mailing Address - Phone:864-608-6624
Mailing Address - Fax:
Practice Address - Street 1:11 E AUGUSTA PL
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-1755
Practice Address - Country:US
Practice Address - Phone:864-214-3494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCOTA.3281224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant