Provider Demographics
NPI:1790717163
Name:PETERSON, JACK A (DO)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2945
Mailing Address - Country:US
Mailing Address - Phone:814-425-1126
Mailing Address - Fax:814-425-1156
Practice Address - Street 1:180 N FRANKLIN ST STE B
Practice Address - Street 2:
Practice Address - City:COCHRANTON
Practice Address - State:PA
Practice Address - Zip Code:16314-9706
Practice Address - Country:US
Practice Address - Phone:814-424-1126
Practice Address - Fax:814-251-1568
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008804L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00163946000003Medicaid
PAG44702Medicare UPIN
PAG44702Medicare UPIN