Provider Demographics
NPI:1427823111
Name:JITER, BRADY
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:
Last Name:JITER
Suffix:
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 1:310 COOK AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62952-1101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 COOK AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:IL
Practice Address - Zip Code:62952-1101
Practice Address - Country:US
Practice Address - Phone:720-576-9480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered