Provider Demographics
NPI:1780016097
Name:PETTERSEN, JENNY TA (FNP)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:TA
Last Name:PETTERSEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-4220
Mailing Address - Country:US
Mailing Address - Phone:510-986-6800
Mailing Address - Fax:
Practice Address - Street 1:818 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-4220
Practice Address - Country:US
Practice Address - Phone:510-986-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2017-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23448363LF0000X
CA757451163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse