Provider Demographics
NPI:1265593560
Name:PETERSON, JON B (DC)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:B
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 1:2611 CLEARWATER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-5953
Mailing Address - Country:US
Mailing Address - Phone:320-656-0200
Mailing Address - Fax:320-656-0204
Practice Address - Street 1:2611 CLEARWATER RD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-5953
Practice Address - Country:US
Practice Address - Phone:320-656-0200
Practice Address - Fax:320-656-0204
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4221111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00039673OtherRAILROAD MEDICARE
MN406S4MIOtherBCBS