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General NPI Number Information
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NPI Number | 1073380580
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Entity Type | Individual
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Provider Name | JESSICA N PETERSEN
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Gender | Female
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Dates
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Enumeration Date | 12/05/2023
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Last Update Date | 12/05/2023
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Provider Practice Location Address
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Address Line | 100 COMMERCE CT
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City | POOLER
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State | GA
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Zip | 31322-9445
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Country | US
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Telephone | 615-560-6622
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Fax |
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Provider Business Mailing Address
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Address Line | 2775 SMITHS XING
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City | RIDGELAND
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State | SC
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Zip | 29936-8325
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Country | US
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Telephone | 940-445-9073
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State | GA
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