Provider Demographics
NPI:1467065540
Name:PETERS, JACOB ALEXANDER
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ALEXANDER
Last Name:PETERS
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 1:520 REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-3383
Mailing Address - Country:US
Mailing Address - Phone:630-401-8311
Mailing Address - Fax:
Practice Address - Street 1:520 REDWOOD DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-3383
Practice Address - Country:US
Practice Address - Phone:630-401-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician