Provider Demographics
NPI:1205062031
Name:PETERSON, JENNIFER M (DOM, AP)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DOM, AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5717 DEREK AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-2413
Mailing Address - Country:US
Mailing Address - Phone:941-926-2909
Mailing Address - Fax:
Practice Address - Street 1:5717 DEREK AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-2413
Practice Address - Country:US
Practice Address - Phone:941-929-2909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 3634171100000X
MA2946225700000X
FL3634171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist