Provider Demographics
NPI:1912367251
Name:PETERSEN, JEFFREY (PT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6640 KANIKSU ST
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-7532
Mailing Address - Country:US
Mailing Address - Phone:208-267-3141
Mailing Address - Fax:208-267-1747
Practice Address - Street 1:6640 KANIKSU ST
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-7532
Practice Address - Country:US
Practice Address - Phone:208-267-3141
Practice Address - Fax:208-267-1747
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2720225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist