Provider Demographics
NPI:1841600137
Name:PETERSON, JACOB LOUIS
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:LOUIS
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6195 FOX POINTE CIR APT C1
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-7597
Mailing Address - Country:US
Mailing Address - Phone:208-629-9680
Mailing Address - Fax:
Practice Address - Street 1:5667 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-5433
Practice Address - Country:US
Practice Address - Phone:801-979-1351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1114904646Medicaid