Provider Demographics
NPI:1932380318
Name:PETERS, JACQUELYN (APRN)
Entity type:Individual
Prefix:MISS
First Name:JACQUELYN
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 WASHINGTON ST FL 14
Mailing Address - Street 2:EIGHT TOWER BRIDGE, SUITE 1400
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2083
Mailing Address - Country:US
Mailing Address - Phone:484-351-3206
Mailing Address - Fax:
Practice Address - Street 1:4450 W EAU GALLIE BLVD STE 250
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7215
Practice Address - Country:US
Practice Address - Phone:321-751-6671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN3203902363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily