Provider Demographics
NPI:1508860487
Name:PETERSON, JACK T JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:T
Last Name:PETERSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 SW HORNE ST
Mailing Address - Street 2:STE 400
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1661
Mailing Address - Country:US
Mailing Address - Phone:785-234-9000
Mailing Address - Fax:785-234-9119
Practice Address - Street 1:631 SW HORNE ST
Practice Address - Street 2:STE 400
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1661
Practice Address - Country:US
Practice Address - Phone:785-234-9000
Practice Address - Fax:785-234-9119
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0422259174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS240007246OtherRAILROAD MEDICARE
KS100516OtherBLUE CROSS
KS100144860BMedicaid
KS628770OtherFIRST GUARD
KS481191346OtherTAX ID
KSD09155Medicare UPIN
KS100516Medicare ID - Type UnspecifiedMEDICARE FOR DR. PETERSON