Provider Demographics
NPI:1952683278
Name:FAVORS PETERSON, JENNIFER DAWN
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:DAWN
Last Name:FAVORS PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DAWN
Other - Last Name:FAVORS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3920 HATCH RD
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-8699
Mailing Address - Country:US
Mailing Address - Phone:209-777-5897
Mailing Address - Fax:
Practice Address - Street 1:3920 HATCH RD
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-8699
Practice Address - Country:US
Practice Address - Phone:209-777-5897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist