Provider Demographics
NPI:1073037982
Name:PETERSEN, JENNIFER SUZANNE (RN, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:SUZANNE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5930 S 58TH ST STE W
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-3653
Mailing Address - Country:US
Mailing Address - Phone:402-423-6402
Mailing Address - Fax:
Practice Address - Street 1:5930 S 58TH ST STE W
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-3653
Practice Address - Country:US
Practice Address - Phone:402-423-6402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE78348163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant