Provider Demographics
NPI:1700019619
Name:PETERSON, JACK NOEL (M D)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:NOEL
Last Name:PETERSON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 CARMENERE DR
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-1107
Mailing Address - Country:US
Mailing Address - Phone:504-466-4575
Mailing Address - Fax:
Practice Address - Street 1:613 CARMENERE DR
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-1107
Practice Address - Country:US
Practice Address - Phone:504-466-4575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD011350207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine