Basic Information
| Provider Information | |||||||||
| NPI: | 1609525633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | AMBER | ||||||||
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| Credential: | MS, RD, LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 SCHOOL ST APT 1 | ||||||||
| Address2: | |||||||||
| City: | ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021193110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084399180 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 732 HARRISON AVE BLDG 2ND | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174148229 | ||||||||
| FaxNumber: | 6176387449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2022 | ||||||||
| LastUpdateDate: | 03/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1085698 | MA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.