Provider Demographics
NPI:1629151428
Name:PEDERSEN, JEFFREY R (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14402 E SPRAGUE AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-2167
Mailing Address - Country:US
Mailing Address - Phone:509-922-2625
Mailing Address - Fax:509-922-4001
Practice Address - Street 1:14402 E SPRAGUE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-2167
Practice Address - Country:US
Practice Address - Phone:509-922-2625
Practice Address - Fax:509-922-4001
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO221207Q00000X
WAOP00001642207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA129223OtherWA LABOR & INDUSTRIES
IDS3143OtherBLUE CROSS
ID000010005518OtherREGENCE BLUESHIELD
WA1043078Medicaid
ID805453200Medicaid
ID1301819OtherDMERC
ID805453200OtherHEALTHY CONNECTIONS
ID000010005518OtherREGENCE BLUESHIELD
ID805453200OtherHEALTHY CONNECTIONS
ID805453200Medicaid
WA8242885Medicaid