Provider Demographics
NPI:1881327971
Name:PETERSON, JESSICA ANN (CPNP-PC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1902 GARDEN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-6638
Mailing Address - Country:US
Mailing Address - Phone:307-851-3606
Mailing Address - Fax:
Practice Address - Street 1:940 E 3RD ST STE 205
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-3251
Practice Address - Country:US
Practice Address - Phone:307-577-4260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY50280363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics