Provider Demographics
NPI:1568177129
Name:PEDERSEN, JON DAVID JR
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:DAVID
Last Name:PEDERSEN
Suffix:JR
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 1:8 ERICO DR
Mailing Address - Street 2:
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06512-1091
Mailing Address - Country:US
Mailing Address - Phone:230-980-1516
Mailing Address - Fax:
Practice Address - Street 1:651 ELM ST
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44502
Practice Address - Country:US
Practice Address - Phone:203-980-1516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0067452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer