Provider Demographics
NPI:1225301989
Name:PETERSON, JESSACA LAUREN (ARDMS)
Entity Type:Individual
Prefix:MS
First Name:JESSACA
Middle Name:LAUREN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ARDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2678 HAMPTON PARK CIR
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36535-1130
Mailing Address - Country:US
Mailing Address - Phone:251-752-0301
Mailing Address - Fax:
Practice Address - Street 1:4100 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45428-9000
Practice Address - Country:US
Practice Address - Phone:937-268-6511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1226132471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography