Provider Demographics
NPI:1861792970
Name:PETERSON, JENNIFER LEE (RPH)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEE
Last Name:PETERSON
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 1:20 26TH ST E
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-3046
Mailing Address - Country:US
Mailing Address - Phone:701-572-4181
Mailing Address - Fax:701-572-0921
Practice Address - Street 1:20 26TH ST E
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-3046
Practice Address - Country:US
Practice Address - Phone:701-572-4181
Practice Address - Fax:701-572-0921
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4489183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist