Provider Demographics
NPI:1275759417
Name:PETERSON, JAN LOUISE (PT)
Entity Type:Individual
Prefix:MS
First Name:JAN
Middle Name:LOUISE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N DUTTON AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4643
Mailing Address - Country:US
Mailing Address - Phone:707-523-2848
Mailing Address - Fax:707-523-2866
Practice Address - Street 1:1400 N DUTTON AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4657
Practice Address - Country:US
Practice Address - Phone:707-523-2848
Practice Address - Fax:707-523-2866
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 9314225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist