Basic Information
| Provider Information | |||||||||
| NPI: | 1578640561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | CARLITA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 W STONE DR | ||||||||
| Address2: | SUITE 6A | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234087220 | ||||||||
| FaxNumber: | 4234087405 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 W STONE DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376606027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237232030 | ||||||||
| FaxNumber: | 4232474110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 06/29/2015 | ||||||||
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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 | 0101240169 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 48169 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 007604092 | 05 | VA | MEDICAID |