Provider Demographics
NPI:1144333022
Name:PETERSON, JENNIFER M (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:701-780-1896
Practice Address - Street 1:1380 S COLUMBIA RD - ALTRU FAMILY MEDICINE CENTER
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-795-2000
Practice Address - Fax:701-780-1896
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6615A208000000X
MN41901208000000X
ND12080208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics