Basic Information
| Provider Information | |||||||||
| NPI: | 1871906107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILBUR | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 600 E DIXIE AVE | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347485925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523233270 | ||||||||
| FaxNumber: | 3523233179 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 N PALMETTO ST | ||||||||
| Address2: | |||||||||
| City: | LEESBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347484419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523233270 | ||||||||
| FaxNumber: | 3523233179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2014 | ||||||||
| LastUpdateDate: | 04/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | OS14979 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | OS14979 | 01 | FL | DOH MQA | OTHER |