Provider Demographics
NPI:1720581952
Name:PETERSON, JESSICA ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:ANN
Last Name:PETERSON
Suffix:
Gender:F
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:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-0334
Mailing Address - Country:US
Mailing Address - Phone:507-626-0618
Mailing Address - Fax:
Practice Address - Street 1:1305 E COLLEGE DR STE B
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-2073
Practice Address - Country:US
Practice Address - Phone:507-591-5027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6480111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor