Provider Demographics
NPI:1225571268
Name:PETERSON, JADE
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 LOTUS LN
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-0600
Mailing Address - Country:US
Mailing Address - Phone:678-910-2952
Mailing Address - Fax:
Practice Address - Street 1:123 N WACKER DR
Practice Address - Street 2:SUITE 1250
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-1743
Practice Address - Country:US
Practice Address - Phone:800-744-5962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36-3644185OtherRETROFIT, INC