Provider Demographics
NPI:1578640561
Name:PETERS, JENNIFER CARLITA (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CARLITA
Last Name:PETERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:111 W STONE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-6027
Practice Address - Country:US
Practice Address - Phone:423-723-2030
Practice Address - Fax:423-247-4110
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240169207Q00000X
TN48169207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007604092Medicaid
TN103I082246Medicare PIN
TN103I938218Medicare PIN
VAVVA652BMedicare PIN
VAC03462Medicare PIN
VA007604092Medicaid