Provider Demographics
NPI:1770521221
Name:PETERSEN, CLINTON JEROME (DC)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:JEROME
Last Name:PETERSEN
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 1:3805 S DOUGLAS HWY
Mailing Address - Street 2:UNIT 1
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-6554
Mailing Address - Country:US
Mailing Address - Phone:307-686-0303
Mailing Address - Fax:307-686-2882
Practice Address - Street 1:3805 S DOUGLAS HWY
Practice Address - Street 2:UNIT 1
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6554
Practice Address - Country:US
Practice Address - Phone:307-686-0303
Practice Address - Fax:307-686-2882
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-04
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY623111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW20553Medicare ID - Type UnspecifiedPROVIDER NUMBER