Basic Information
| Provider Information | |||||||||
| NPI: | 1669988440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LISW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5555 WATERLOO RD | ||||||||
| Address2: | |||||||||
| City: | CANAL WINCHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431109542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143955160 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1490 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142520731 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2017 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I-0008967 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.