Provider Demographics
NPI:1760258701
Name:PETERSEN, JEN (RPH)
Entity Type:Individual
Prefix:
First Name:JEN
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 303
Mailing Address - Street 2:
Mailing Address - City:SPIRIT LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:51360-0303
Mailing Address - Country:US
Mailing Address - Phone:712-336-4731
Mailing Address - Fax:800-604-9151
Practice Address - Street 1:2202 17TH ST
Practice Address - Street 2:
Practice Address - City:SPIRIT LAKE
Practice Address - State:IA
Practice Address - Zip Code:51360
Practice Address - Country:US
Practice Address - Phone:712-336-4731
Practice Address - Fax:800-604-9151
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17899183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist