Provider Demographics
NPI:1609265826
Name:PETERSON, JESSICA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:389 W 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-2726
Mailing Address - Country:US
Mailing Address - Phone:541-683-3618
Mailing Address - Fax:541-686-5744
Practice Address - Street 1:389 W 29TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-2726
Practice Address - Country:US
Practice Address - Phone:541-683-3618
Practice Address - Fax:541-686-5744
Is Sole Proprietor?:No
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201230175LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse