Provider Demographics
NPI:1649841941
Name:PETERSON, JACOB M
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:M
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 1:1010 GARDENVIEW ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:OH
Mailing Address - Zip Code:44240-3327
Mailing Address - Country:US
Mailing Address - Phone:330-907-4076
Mailing Address - Fax:
Practice Address - Street 1:1010 GARDENVIEW ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:OH
Practice Address - Zip Code:44240-3327
Practice Address - Country:US
Practice Address - Phone:330-907-4076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide