Provider Demographics
NPI:1700841178
Name:PETERSON, JENNIFER S (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:PETERSON
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 1:1204 JOSEPH ST # 2
Mailing Address - Street 2:
Mailing Address - City:DODGEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53533-9670
Mailing Address - Country:US
Mailing Address - Phone:608-574-5044
Mailing Address - Fax:
Practice Address - Street 1:1204 JOSEPH ST # 2
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-9670
Practice Address - Country:US
Practice Address - Phone:608-574-5044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41433-020207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1040967OtherPHYSICIANS PLUS
WI34220800Medicaid
WI9990OtherDEAN HEALTH INSURANCE
WI1040967OtherPHYSICIANS PLUS
WI9990OtherDEAN HEALTH INSURANCE
WI070017011Medicare PIN