Provider Demographics
NPI:1609525633
Name:PETERS, JESSICA AMBER (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:AMBER
Last Name:PETERS
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 SCHOOL ST APT 1
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-3110
Mailing Address - Country:US
Mailing Address - Phone:508-439-9180
Mailing Address - Fax:
Practice Address - Street 1:732 HARRISON AVE BLDG 2ND
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2309
Practice Address - Country:US
Practice Address - Phone:617-414-8229
Practice Address - Fax:617-638-7449
Is Sole Proprietor?:No
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1085698133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered