Provider Demographics
NPI:1013915313
Name:PETERSON HIGHLEY, JENNIFER LYNNE (OD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNNE
Last Name:PETERSON HIGHLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 ANTIGUA CT
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-2717
Mailing Address - Country:US
Mailing Address - Phone:775-722-3779
Mailing Address - Fax:
Practice Address - Street 1:844 W NYE LN STE 104
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-1571
Practice Address - Country:US
Practice Address - Phone:775-882-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV486152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100502286Medicaid
NV100502286Medicaid
NVV31845Medicare PIN