Provider Demographics
NPI:1962161307
Name:JETER, SAMANTHA ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:ELIZABETH
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 1:132 PLYMOUTH CT
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-2994
Mailing Address - Country:US
Mailing Address - Phone:636-698-5875
Mailing Address - Fax:
Practice Address - Street 1:132 PLYMOUTH CT
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-2994
Practice Address - Country:US
Practice Address - Phone:636-698-5875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021047772224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant