Provider Demographics
NPI:1942556766
Name:PETERSON, JENNA LYNN (LMT)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 W GUADALUPE RD UNIT 2077
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-7784
Mailing Address - Country:US
Mailing Address - Phone:260-413-4757
Mailing Address - Fax:
Practice Address - Street 1:325 N ALMA SCHOOL RD STE 3
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-4379
Practice Address - Country:US
Practice Address - Phone:260-413-4757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-16104225700000X
322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children