Provider Demographics
NPI:1174770648
Name:JETERS, NICHOLE (LCPC)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:JETERS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-1624
Mailing Address - Fax:618-724-4628
Practice Address - Street 1:4241 HWY 14 W
Practice Address - Street 2:
Practice Address - City:CHRISTOPHER
Practice Address - State:IL
Practice Address - Zip Code:62822-1037
Practice Address - Country:US
Practice Address - Phone:618-724-2401
Practice Address - Fax:618-724-4628
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009521101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health