Provider Demographics
NPI:1427179183
Name:PETERSON, JESSICA (OTRL)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 RIVERS END DR
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-8009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 MIDDLEFORD RD
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-3638
Practice Address - Country:US
Practice Address - Phone:302-628-5608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEU10826225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEU10826OtherLICENSE NUMBER