Provider Demographics
NPI:1689790917
Name:PETERSON, JEFFREY HAL (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:HAL
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8290 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-4006
Mailing Address - Country:US
Mailing Address - Phone:520-296-4496
Mailing Address - Fax:520-296-5676
Practice Address - Street 1:8290 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-4006
Practice Address - Country:US
Practice Address - Phone:520-296-4496
Practice Address - Fax:520-296-5676
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5569111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZDC5569Medicare ID - Type Unspecified
AZU65885Medicare UPIN