Provider Demographics
NPI:1548808322
Name:PETERS, JESSICA LYNN (LPN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:PETERS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:699 BRUCE DR
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-1109
Mailing Address - Country:US
Mailing Address - Phone:516-355-1480
Mailing Address - Fax:
Practice Address - Street 1:699 BRUCE DR
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-1109
Practice Address - Country:US
Practice Address - Phone:516-355-1480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336813-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse