Basic Information
| Provider Information | |||||||||
| NPI: | 1568544609 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7315 212TH ST SW | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257759474 | ||||||||
| FaxNumber: | 4256703554 | ||||||||
| Practice Location | |||||||||
| Address1: | 7315 212TH ST SW | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980267610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257759474 | ||||||||
| FaxNumber: | 4256703554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 00034179 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8211591 | 05 | WA | MEDICAID |