Provider Demographics
NPI:1871906107
Name:PETERSON, JESSICA (DO)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:WILBUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2670 RETRIEVER DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-5488
Mailing Address - Country:US
Mailing Address - Phone:954-257-4158
Mailing Address - Fax:
Practice Address - Street 1:211 NE 54TH ST STE 201
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-4330
Practice Address - Country:US
Practice Address - Phone:816-453-6777
Practice Address - Fax:816-454-3601
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20220311932084P0800X
FLOS149792084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS14979OtherDOH MQA