Provider Demographics
NPI:1851388250
Name:PETERSON, JESSICA JOY (PAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JOY
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PAC
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 1866
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-1866
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:218 S US HIGHWAY 141
Practice Address - Street 2:STE 100
Practice Address - City:CRIVITZ
Practice Address - State:WI
Practice Address - Zip Code:54114-1677
Practice Address - Country:US
Practice Address - Phone:715-854-7477
Practice Address - Fax:715-854-7785
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1846023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42869400Medicaid
WIP003033413Medicare Oscar/Certification
WI004240160Medicare Oscar/Certification
Q44735Medicare UPIN
WI003940115Medicare Oscar/Certification