Provider Demographics
NPI:1316379597
Name:PETERSON, JENNIFER LEE (APRN CNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:APRN CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2056 HIGH DR
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-2638
Mailing Address - Country:US
Mailing Address - Phone:320-290-6326
Mailing Address - Fax:
Practice Address - Street 1:119 30TH AVE W
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3433
Practice Address - Country:US
Practice Address - Phone:320-762-6226
Practice Address - Fax:320-219-7149
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1408449163W00000X
MNR 140844-9363LF0000X
MNCNP0445363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse