Provider Demographics
NPI:1306228366
Name:PETERSON, JORDAN DANE (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:DANE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 UNIVERSITY AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-8200
Mailing Address - Country:US
Mailing Address - Phone:515-241-2400
Mailing Address - Fax:514-241-2401
Practice Address - Street 1:6000 UNIVERSITY AVE STE 300
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8200
Practice Address - Country:US
Practice Address - Phone:515-241-2400
Practice Address - Fax:515-241-2401
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-25
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-44443207R00000X
IAR-10359207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine