Provider Demographics
NPI:1336859693
Name:PETERSON, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 325
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89440-0325
Mailing Address - Country:US
Mailing Address - Phone:775-430-0305
Mailing Address - Fax:
Practice Address - Street 1:121 S B ST UNIT 1
Practice Address - Street 2:
Practice Address - City:VIRGINIA CITY
Practice Address - State:NV
Practice Address - Zip Code:89440-9829
Practice Address - Country:US
Practice Address - Phone:775-430-0305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide