MEDICARE: JENNIFER KEEVER PETERKEN MSW, LCSWA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	P019107	NC

General Provider Information

NPI Number	:	1659057172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER KEEVER PETERKEN MSW, LCSWA

Provider Business Mailing Address
First Line	:	7019 CAYMAN CT
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28405-8371
Country	:	US
Telephone Number	:	910-620-8276
Fax Number	:

Provider Business Practice Location Address
First Line	:	720 N 3RD ST STE 401
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28401-3474
Country	:	US
Telephone Number	:	910-769-9126
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2023
Last Update Date	:	06/28/2023

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