Healthcare Provider Details

I. General information

NPI: 1245322155
Provider Name (Legal Business Name): JENNIFER MARIE PETERSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 CENTRAL AVE LYNN COMMUNITY HEALTH CENTER
LYNN MA
01901-1201
US

IV. Provider business mailing address

20 CENTRAL AVE LYNN COMMUNITY HEALTH CENTER
LYNN MA
01901-1201
US

V. Phone/Fax

Practice location:
  • Phone: 781-477-7222
  • Fax:
Mailing address:
  • Phone: 781-477-7222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number113398
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2284745
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2284745
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: