Provider Demographics
NPI:1528117298
Name:JONES, PEGGY PETTERSON
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:PETTERSON
Last Name:JONES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19902 REGENCY RUN
Mailing Address - Street 2:
Mailing Address - City:GARDEN RIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:78266-2330
Mailing Address - Country:US
Mailing Address - Phone:210-221-6017
Mailing Address - Fax:210-221-7850
Practice Address - Street 1:2050 WORTH RD
Practice Address - Street 2:ATTN MCHO CL Q
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-7533
Practice Address - Country:US
Practice Address - Phone:210-221-6195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDD0764133V00000X
KYKY1679133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered