Provider Demographics
NPI:1194462481
Name:PETERSON, JESSIE L (PT, DPT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT, DPT, LAT, ATC
Other - Prefix:
Other - First Name:JESSIE
Other - Middle Name:L
Other - Last Name:MORWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5271 MINERAL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-8345
Mailing Address - Country:US
Mailing Address - Phone:702-468-1266
Mailing Address - Fax:
Practice Address - Street 1:7351 PRAIRIE FALCON RD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0820
Practice Address - Country:US
Practice Address - Phone:702-968-0520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-18
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2255A2300X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer