Provider Demographics
NPI:1205220738
Name:JESSICA PETERSEN DC LTD
Entity Type:Organization
Organization Name:JESSICA PETERSEN DC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:708-422-3300
Mailing Address - Street 1:5505 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2351
Mailing Address - Country:US
Mailing Address - Phone:708-422-3300
Mailing Address - Fax:708-422-3303
Practice Address - Street 1:4907 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2503
Practice Address - Country:US
Practice Address - Phone:708-422-3300
Practice Address - Fax:708-422-3303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-23
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011324111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty