Provider Demographics
NPI:1407235948
Name:PETERSEN, JASON (OD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1201
Mailing Address - Country:US
Mailing Address - Phone:208-263-8501
Mailing Address - Fax:208-263-9713
Practice Address - Street 1:307 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1201
Practice Address - Country:US
Practice Address - Phone:208-263-8501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100336152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist