Provider Demographics
NPI:1467599761
Name:PETERSON, JENNY LYNN (RN)
Entity Type:Individual
Prefix:MS
First Name:JENNY
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 SE 86TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-1044
Mailing Address - Country:US
Mailing Address - Phone:503-262-0566
Mailing Address - Fax:
Practice Address - Street 1:13317 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3335
Practice Address - Country:US
Practice Address - Phone:503-760-9606
Practice Address - Fax:503-760-9609
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200141254RN163WP0808X
OR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator