Healthcare Provider Details

I. General information

NPI: 1497666911
Provider Name (Legal Business Name): JENNIFER PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7819A ROAD 37
LINGLE WY
82223-8557
US

IV. Provider business mailing address

7819A ROAD 37
LINGLE WY
82223-8557
US

V. Phone/Fax

Practice location:
  • Phone: 307-575-9096
  • Fax:
Mailing address:
  • Phone: 307-575-9096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: