Healthcare Provider Details

I. General information

NPI: 1851388250
Provider Name (Legal Business Name): JESSICA JOY PETERSON PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 S US HIGHWAY 141 STE 100
CRIVITZ WI
54114-1677
US

IV. Provider business mailing address

PO BOX 1866
GREEN BAY WI
54305-1866
US

V. Phone/Fax

Practice location:
  • Phone: 715-854-7477
  • Fax: 715-854-7785
Mailing address:
  • Phone: 920-445-7222
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1846023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: