Provider Demographics
NPI:1811440274
Name:PETERSEN, JACOB (DPT)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8874 WOODMAYR CIR
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:IA
Mailing Address - Zip Code:50211-1842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2160 APPIAN WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2576
Practice Address - Country:US
Practice Address - Phone:510-724-1248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291765208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation