Provider Demographics
NPI:1295176808
Name:PETERSON, JENNIFER MARIE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2261 W NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3805
Mailing Address - Country:US
Mailing Address - Phone:321-433-1789
Mailing Address - Fax:
Practice Address - Street 1:2261 W NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3805
Practice Address - Country:US
Practice Address - Phone:321-433-1789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS50491183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist