Provider Demographics
NPI:1669783320
Name:PEDERSEN, JAMES A (LAC)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 JAMES ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2199
Mailing Address - Country:US
Mailing Address - Phone:630-347-4678
Mailing Address - Fax:
Practice Address - Street 1:321 JAMES ST
Practice Address - Street 2:SUITE 105
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2199
Practice Address - Country:US
Practice Address - Phone:630-347-4678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000807171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist