Provider Demographics
NPI:1568981314
Name:PETERSON, JEFFREY JOSEPH
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JOSEPH
Last Name:PETERSON
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 1:162 N 400 E STE A105
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-7192
Mailing Address - Country:US
Mailing Address - Phone:435-275-8911
Mailing Address - Fax:435-200-9442
Practice Address - Street 1:162 N 400 E STE A-105
Practice Address - Street 2:
Practice Address - City:ST. GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:435-275-8911
Practice Address - Fax:435-200-9442
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician