Provider Demographics
NPI:1013129857
Name:PETERSON, JONATHAN J (DC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 E SADDLE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-5595
Mailing Address - Country:US
Mailing Address - Phone:480-208-3835
Mailing Address - Fax:
Practice Address - Street 1:3076 E. CHANDLER HEIGHTS RD.
Practice Address - Street 2:SUITE 107
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298
Practice Address - Country:US
Practice Address - Phone:480-840-3663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7814111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ116226Medicare PIN