Healthcare Provider Details

I. General information

NPI: 1558270975
Provider Name (Legal Business Name): JACLYN PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N BROADWAY ST
BALTIMORE MD
21287-0031
US

IV. Provider business mailing address

201 N BROADWAY ST
BALTIMORE MD
21287-0031
US

V. Phone/Fax

Practice location:
  • Phone: 410-614-0036
  • Fax:
Mailing address:
  • Phone: 773-315-4269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberR276832
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: