Provider Demographics
NPI:1912672239
Name:JETER, ANGELIQUE ASHLEY
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:ASHLEY
Last Name:JETER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 MAPLE AVE APT A2
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-4369
Mailing Address - Country:US
Mailing Address - Phone:973-289-4895
Mailing Address - Fax:
Practice Address - Street 1:181 NEW RD STE 304
Practice Address - Street 2:
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054-5625
Practice Address - Country:US
Practice Address - Phone:800-805-0759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician