Provider Demographics
NPI:1063221646
Name:PETERSON, MARY (ADMINISTRATOR)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 SILVER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-4446
Mailing Address - Country:US
Mailing Address - Phone:904-356-3022
Mailing Address - Fax:904-356-3022
Practice Address - Street 1:1622 SILVER ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-4446
Practice Address - Country:US
Practice Address - Phone:904-356-3022
Practice Address - Fax:904-350-9165
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL8638310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility