=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861741480
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANNE LYNN PETERSON P.A.-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2012
-----------------------------------------------------
Last Update Date | 05/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 S 4TH AVE INTAKE PROVIDER
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85003-2138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-876-9124
-----------------------------------------------------
Fax | 602-253-3431
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 S 4TH AVE
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85003-2138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-876-9124
-----------------------------------------------------
Fax | 602-253-3431
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 5187
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------