Provider Demographics
NPI:1861741480
Name:PETERSON, JEANNE LYNN (PA-C)
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:201 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003-2138
Mailing Address - Country:US
Mailing Address - Phone:602-876-9124
Mailing Address - Fax:602-253-3431
Practice Address - Street 1:201 S 4TH AVE
Practice Address - Street 2:INTAKE PROVIDER
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85003-2138
Practice Address - Country:US
Practice Address - Phone:602-876-9124
Practice Address - Fax:602-253-3431
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ5187363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant