Provider Demographics
NPI:1629478110
Name:PETERSON, JESSICA LAUREN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LAUREN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6297 PGA BLVD
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-4000
Mailing Address - Country:US
Mailing Address - Phone:561-627-2505
Mailing Address - Fax:
Practice Address - Street 1:6297 PGA BLVD
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-4000
Practice Address - Country:US
Practice Address - Phone:561-627-2505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52159183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist