Provider Demographics
NPI:1871689174
Name:PETERSEN, JENNIFER L (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:L
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 S CLEVELAND MASSILLON RD
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-3024
Mailing Address - Country:US
Mailing Address - Phone:330-665-4100
Mailing Address - Fax:330-665-4190
Practice Address - Street 1:762 S CLEVELAND MASSILLON RD
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3024
Practice Address - Country:US
Practice Address - Phone:330-665-4100
Practice Address - Fax:330-665-4190
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002511363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicare ID - Type Unspecified