=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497666911
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER PETERSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2026
-----------------------------------------------------
Last Update Date | 09/14/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7819A ROAD 37
-----------------------------------------------------
City | LINGLE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82223-8557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-575-9096
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7819A ROAD 37
-----------------------------------------------------
City | LINGLE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82223-8557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-575-9096
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------