Provider Demographics
NPI:1407613425
Name:PETERSON, JACOB DEAN
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DEAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 STAR VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-8552
Mailing Address - Country:US
Mailing Address - Phone:307-221-8090
Mailing Address - Fax:
Practice Address - Street 1:510 STAR VALLEY DR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-8552
Practice Address - Country:US
Practice Address - Phone:307-221-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program