Healthcare Provider Details

I. General information

NPI: 1285121988
Provider Name (Legal Business Name): JENNIFER LYNN PETERSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2631 WILLIAMSBURG AVENUE SUITE 202
GENEVA IL
60134-1111
US

IV. Provider business mailing address

2631 WILLIAMSBURG AVENUE SUITE 202
GENEVA IL
60134-1111
US

V. Phone/Fax

Practice location:
  • Phone: 815-981-4742
  • Fax: 630-402-9169
Mailing address:
  • Phone: 815-981-4742
  • Fax: 630-402-9169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.017872
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number041369391
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: