Provider Demographics
NPI:1437821469
Name:PEDERSEN, JACOB DANIEL (INDEPENDENT DUTY CO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DANIEL
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:INDEPENDENT DUTY CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-2424
Mailing Address - Country:US
Mailing Address - Phone:218-529-3131
Mailing Address - Fax:
Practice Address - Street 1:249 GLASSON
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78406-1817
Practice Address - Country:US
Practice Address - Phone:361-939-0291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman