Provider Demographics
NPI:1164936985
Name:PETERS, JACOB DUANE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DUANE
Last Name:PETERS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6149
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97007-0149
Mailing Address - Country:US
Mailing Address - Phone:503-359-8501
Mailing Address - Fax:503-434-8597
Practice Address - Street 1:2725 SW CEDAR HILLS BLVD STE 2A
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-1344
Practice Address - Country:US
Practice Address - Phone:503-352-6000
Practice Address - Fax:503-434-8597
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA185067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine