Provider Demographics
NPI:1093331126
Name:PETERSON, JESSICA LYNN (ND, LAC)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10653 MILLARD DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9150
Mailing Address - Country:US
Mailing Address - Phone:708-712-1097
Mailing Address - Fax:
Practice Address - Street 1:1139 JOLIET ST
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1926
Practice Address - Country:US
Practice Address - Phone:219-641-7359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT099.0134092175F00000X
IN84000210A171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty