Provider Demographics
NPI:1962904722
Name:PETERS, JELLIRICA
Entity type:Individual
Prefix:
First Name:JELLIRICA
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JELLIRICA
Other - Middle Name:
Other - Last Name:TAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3001 BEE CAVES RD STE 220
Mailing Address - Street 2:
Mailing Address - City:ROLLINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:78746-5590
Mailing Address - Country:US
Mailing Address - Phone:512-229-9691
Mailing Address - Fax:
Practice Address - Street 1:3001 BEE CAVES RD STE 220
Practice Address - Street 2:
Practice Address - City:ROLLINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:78746-5590
Practice Address - Country:US
Practice Address - Phone:512-777-2591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136929363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health