Provider Demographics
NPI:1881268092
Name:PETERSON, JENNIFER MEGAN (OD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MEGAN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 STATE RT 17 N STE 6
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07662-3398
Mailing Address - Country:US
Mailing Address - Phone:201-368-2444
Mailing Address - Fax:
Practice Address - Street 1:485 ROUTE-1 S BUILDING A
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08830
Practice Address - Country:US
Practice Address - Phone:989-225-4668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00703000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist