Provider Demographics
NPI:1760414544
Name:PETTERSON, JEAN (DO)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:PETTERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 TITUS PLACE
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:NY
Mailing Address - Zip Code:13856
Mailing Address - Country:US
Mailing Address - Phone:607-865-2400
Mailing Address - Fax:607-865-7305
Practice Address - Street 1:2 TITUS PLACE
Practice Address - Street 2:
Practice Address - City:WALTON
Practice Address - State:NY
Practice Address - Zip Code:13856
Practice Address - Country:US
Practice Address - Phone:607-865-2400
Practice Address - Fax:607-865-7305
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH9819208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30009798Medicaid
NH30009798Medicaid
NHG69540Medicare UPIN
NHT400106665Medicare PIN