Provider Demographics
NPI:1881921419
Name:PETERSON, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
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 1:6160 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE B 90
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4578
Mailing Address - Country:US
Mailing Address - Phone:770-673-0093
Mailing Address - Fax:
Practice Address - Street 1:6160 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE B 90
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4578
Practice Address - Country:US
Practice Address - Phone:770-673-0093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009818225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist