Provider Demographics
NPI:1841389699
Name:PETERSEN, JEFFREY (PT MOMT)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:PT MOMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1844 E BASELINE RD STE C5
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1506
Mailing Address - Country:US
Mailing Address - Phone:480-833-1005
Mailing Address - Fax:480-833-1312
Practice Address - Street 1:1844 E BASELINE RD STE C5
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1506
Practice Address - Country:US
Practice Address - Phone:480-833-1005
Practice Address - Fax:480-833-1312
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1295225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ175499Medicaid
AZ79356Medicare ID - Type Unspecified
AZ175499Medicaid
AZZ79354Medicare PIN