Provider Demographics
NPI:1942057278
Name:PETERSON, JODI LEANN (RN)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:LEANN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:LEANN
Other - Last Name:EBERLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16445 MUSTANG LN NE
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-2528
Mailing Address - Country:US
Mailing Address - Phone:503-949-1387
Mailing Address - Fax:
Practice Address - Street 1:4760 PORTLAND RD NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1760
Practice Address - Country:US
Practice Address - Phone:503-949-1387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200243022RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse