Healthcare Provider Details

I. General information

NPI: 1558299172
Provider Name (Legal Business Name): JESSICA LORRAINE PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 HARRISON BLVD
OGDEN UT
84403-3195
US

IV. Provider business mailing address

416 E 3075 N
NORTH OGDEN UT
84414-1938
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-2800
  • Fax:
Mailing address:
  • Phone: 801-387-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number13593256-4901
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: