Provider Demographics
NPI:1164621595
Name:PETERSON, JENNIFER LYNNE (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 E BROADWAY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-1599
Mailing Address - Country:US
Mailing Address - Phone:480-377-9320
Mailing Address - Fax:480-377-9327
Practice Address - Street 1:4646 E. GREENWAY RD
Practice Address - Street 2:SUITE 110
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032
Practice Address - Country:US
Practice Address - Phone:602-923-6750
Practice Address - Fax:602-923-6804
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ225100000X
AZ7752225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist