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General NPI Number Information
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NPI Number | 1194289983
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Entity Type | Individual
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Provider Name | JACKIE LENNETT PETERSON RD CDCES
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Gender | Female
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Dates
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Enumeration Date | 01/25/2019
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Last Update Date | 08/14/2023
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Provider Practice Location Address
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Address Line | 213 ILENE DR
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City | PLEASANT HILL
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State | CA
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Zip | 94523-2226
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Country | US
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Telephone | 925-819-0414
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Fax |
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Provider Business Mailing Address
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Address Line | 1888 BERKELEY WAY APT 306
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City | BERKELEY
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State | CA
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Zip | 94703-1684
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Country | US
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Telephone | 925-819-0414
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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 | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 86100784
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License Number State | CA
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