Provider Demographics
NPI:1609655240
Name:PETERS, JACK DAVID
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:DAVID
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 1:800 W STADIUM AVE
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47907-2046
Mailing Address - Country:US
Mailing Address - Phone:765-496-0502
Mailing Address - Fax:
Practice Address - Street 1:800 W STADIUM AVE
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907-2046
Practice Address - Country:US
Practice Address - Phone:765-496-0502
Practice Address - Fax:765-496-1239
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer