Provider Demographics
NPI:1467536656
Name:PETETT, JEFFREY SCOTT (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SCOTT
Last Name:PETETT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10622 SE CARR RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5824
Mailing Address - Country:US
Mailing Address - Phone:425-277-2225
Mailing Address - Fax:425-277-1591
Practice Address - Street 1:10622 SE CARR RD
Practice Address - Street 2:SUITE A
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5824
Practice Address - Country:US
Practice Address - Phone:425-277-2225
Practice Address - Fax:425-277-1591
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACHOOOO2306111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA41194OtherL&I
WA8427031Medicaid
WA911597946OtherTAX ID#
WA41194OtherL&I
WAU2013381Medicare UPIN