Provider Demographics
NPI:1740833011
Name:PETERSON, JENNAY AVE
Entity type:Individual
Prefix:
First Name:JENNAY
Middle Name:AVE
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 1:289 N WYCOMBE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:PA
Mailing Address - Zip Code:19050-1733
Mailing Address - Country:US
Mailing Address - Phone:610-937-3448
Mailing Address - Fax:
Practice Address - Street 1:289 N WYCOMBE AVE
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:PA
Practice Address - Zip Code:19050-1733
Practice Address - Country:US
Practice Address - Phone:610-937-3448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000205483163W00000X
PA652288163W00000X
374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse