Provider Demographics
NPI:1750618021
Name:PETERS, JENNIFER DOROTHEA (FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DOROTHEA
Last Name:PETERS
Suffix:
Gender:F
Credentials:FNP
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 7102
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-0102
Mailing Address - Country:US
Mailing Address - Phone:909-435-5019
Mailing Address - Fax:
Practice Address - Street 1:3350 LA JOLLA VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0002
Practice Address - Country:US
Practice Address - Phone:909-435-5019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-07
Last Update Date:2009-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA663212163W00000X
CA17826363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA663212OtherRN LICENSE
CA17826OtherNURSE PRACTITIONER CERTIFICATE
CAF1207048OtherAANP CERTIFICATION
CA69543OtherPUBLIC HEALTH NURSE CERTIFICATE