Provider Demographics
NPI:1902128887
Name:PETERSEN, JESSICA LANIER (RPH)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LANIER
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 S CANNON BLVD
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-6233
Mailing Address - Country:US
Mailing Address - Phone:704-938-7021
Mailing Address - Fax:704-938-6189
Practice Address - Street 1:1310 S CANNON BLVD
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-6233
Practice Address - Country:US
Practice Address - Phone:704-938-7021
Practice Address - Fax:704-938-6189
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15639183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist