Provider Demographics
NPI:1366811739
Name:PETERSON, JAMIE (RN)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93433-2245
Mailing Address - Country:US
Mailing Address - Phone:805-473-7050
Mailing Address - Fax:805-474-7473
Practice Address - Street 1:286 S 16TH ST
Practice Address - Street 2:
Practice Address - City:GROVER BEACH
Practice Address - State:CA
Practice Address - Zip Code:93433-2245
Practice Address - Country:US
Practice Address - Phone:805-473-7050
Practice Address - Fax:805-474-7473
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA820652163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management