Provider Demographics
NPI:1609751429
Name:JETER, LATOISHANAI
Entity type:Individual
Prefix:
First Name:LATOISHANAI
Middle Name:
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 1:236 ROSLYN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-3941
Mailing Address - Country:US
Mailing Address - Phone:716-510-3645
Mailing Address - Fax:
Practice Address - Street 1:1515 KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1436
Practice Address - Country:US
Practice Address - Phone:716-510-3645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No171400000XOther Service ProvidersHealth & Wellness Coach
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty