Provider Demographics
NPI:1518178870
Name:PETERSEN, JACKLYN ELAINE (LPN)
Entity type:Individual
Prefix:MRS
First Name:JACKLYN
Middle Name:ELAINE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 PERRYSBURG HOLLAND RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-9582
Mailing Address - Country:US
Mailing Address - Phone:419-324-0949
Mailing Address - Fax:
Practice Address - Street 1:1905 PERRYSBURG HOLLAND RD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528-9582
Practice Address - Country:US
Practice Address - Phone:419-324-0949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-110467164W00000X
OHLPN.110467.MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse