Provider Demographics
NPI:1083347223
Name:PETERSON, JAKESHIA LYNETTE
Entity Type:Individual
Prefix:
First Name:JAKESHIA
Middle Name:LYNETTE
Last Name:PETERSON
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 1:11935 ABERCORN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-1918
Mailing Address - Country:US
Mailing Address - Phone:912-344-3109
Mailing Address - Fax:
Practice Address - Street 1:1211 KING GEORGE BLVD APT 5
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-9504
Practice Address - Country:US
Practice Address - Phone:912-433-0618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program