Provider Demographics
NPI:1023594215
Name:PETERSON, EMILY JEAN (DC)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:JEAN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 SHERMAN ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2425
Mailing Address - Country:US
Mailing Address - Phone:651-225-1102
Mailing Address - Fax:612-977-1208
Practice Address - Street 1:360 SHERMAN ST STE 400
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-225-1102
Practice Address - Fax:612-977-1208
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6485111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor