Healthcare Provider Details

I. General information

NPI: 1013361666
Provider Name (Legal Business Name): JESSICA ARETHA PETERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6250 S COTTAGE GROVE AVE
CHICAGO IL
60637-2530
US

IV. Provider business mailing address

1136 S DELANO CT W
CHICAGO IL
60605-3740
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-2193
  • Fax:
Mailing address:
  • Phone: 813-610-5996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number036163367
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number036163367
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: