Provider Demographics
NPI:1124019948
Name:PETERSON, JACQUELYN
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
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 1:95 E CHAUTAUQUA ST
Mailing Address - Street 2:PO BOX 168
Mailing Address - City:MAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14757-1017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:320 PRATHER AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6820
Practice Address - Country:US
Practice Address - Phone:716-753-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-01
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007012363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02342107Medicaid
NY007012Medicaid
NYPA1381Medicare PIN
NYJ400003926Medicare PIN
NYCC1485Medicare ID - Type Unspecified
NYPA1383Medicare PIN
NYPA1386Medicare PIN
NYP11669Medicare UPIN
NY007012Medicaid
NYPA1382Medicare PIN
NYPA1385Medicare PIN