Provider Demographics
NPI:1366474975
Name:PETERSON, JANE A (APRN)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 BRENT DR
Mailing Address - Street 2:
Mailing Address - City:BONNER SPRINGS
Mailing Address - State:KS
Mailing Address - Zip Code:66012
Mailing Address - Country:US
Mailing Address - Phone:402-415-3868
Mailing Address - Fax:
Practice Address - Street 1:2220 HOLMES ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-2639
Practice Address - Country:US
Practice Address - Phone:816-235-5963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006031910363LF0000X
KS44809363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47078557536Medicaid
NE279442Medicare ID - Type Unspecified
NE47078557536Medicaid