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General NPI Number Information
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NPI Number | 1073638227
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Entity Type | Individual
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Provider Name | JAYANTHI KRISHNAMOORTHY PETERS M.D.
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Gender | Female
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Dates
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Enumeration Date | 03/20/2007
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Last Update Date | 04/10/2024
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Provider Practice Location Address
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Address Line | 300 68TH ST SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49548-6927
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Country | US
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Telephone | 616-559-5896
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Fax |
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Provider Business Mailing Address
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Address Line | 250 N SHADELAND AVE SUITE 130
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City | INDIANAPOLIS
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State | IN
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Zip | 46219-4959
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Country | US
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Telephone |
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 35084122
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | 35084122
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 01070092A
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License Number State | IN
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Taxonomy #4
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 4301106462
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License Number State | MI
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