Provider Demographics
NPI:1184202251
Name:PETERSON, JENNIFER M (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 BELMONT RD NW APT A
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-5490
Mailing Address - Country:US
Mailing Address - Phone:202-309-0810
Mailing Address - Fax:
Practice Address - Street 1:1906 BELLEVIEW AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1838
Practice Address - Country:US
Practice Address - Phone:540-981-7120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program