Provider Demographics
NPI:1083013502
Name:PETERS, JILL ANNA PATRICIA
Entity Type:Individual
Prefix:
First Name:JILL ANNA
Middle Name:PATRICIA
Last Name:PETERS
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 1:74 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3417
Mailing Address - Country:US
Mailing Address - Phone:862-579-1013
Mailing Address - Fax:
Practice Address - Street 1:74 HOWARD ST
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3417
Practice Address - Country:US
Practice Address - Phone:862-579-1013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-20
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTP0406300253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care