Provider Demographics
NPI:1699048165
Name:JETER, CHENOA AMILL (PTA)
Entity type:Individual
Prefix:
First Name:CHENOA
Middle Name:AMILL
Last Name:JETER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10226 GREEN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-3231
Mailing Address - Country:US
Mailing Address - Phone:206-551-5969
Mailing Address - Fax:
Practice Address - Street 1:615 RANCHO LN
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-1717
Practice Address - Country:US
Practice Address - Phone:314-839-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011008730225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant