Provider Demographics
NPI:1477743995
Name:PETERS, JENNIE L (PMHNP-BC, FNP)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:L
Last Name:PETERS
Suffix:
Gender:F
Credentials:PMHNP-BC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6032 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7018
Mailing Address - Country:US
Mailing Address - Phone:262-287-1999
Mailing Address - Fax:262-287-0884
Practice Address - Street 1:6032 40TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7018
Practice Address - Country:US
Practice Address - Phone:262-287-1999
Practice Address - Fax:262-287-0884
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2022152805363LP0808X
WI3146363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily