Provider Demographics
NPI:1023537677
Name:PETERSON, JENNIFER (APRN-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:APRN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 S SETH CHILD RD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-3003
Mailing Address - Country:US
Mailing Address - Phone:785-776-2318
Mailing Address - Fax:
Practice Address - Street 1:315 S SETH CHILD RD
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-3003
Practice Address - Country:US
Practice Address - Phone:785-776-2813
Practice Address - Fax:785-776-2851
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-77876-072363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS53-77876-072OtherSTATE LICENSE