Healthcare Provider Details

I. General information

NPI: 1114783693
Provider Name (Legal Business Name): JENNIFER DELIA PETERSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2024
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 E FAIRWAY DR
ORANGE CA
92866-3202
US

IV. Provider business mailing address

950 E FAIRWAY DR
ORANGE CA
92866-3202
US

V. Phone/Fax

Practice location:
  • Phone: 714-478-0361
  • Fax:
Mailing address:
  • Phone: 714-478-0361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number95100231
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: