Provider Demographics
NPI:1831575745
Name:PETERSON, JODI LYNN
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 N 27TH ST
Mailing Address - Street 2:STE 101
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-0100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 N 27TH ST
Practice Address - Street 2:STE 101
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-0100
Practice Address - Country:US
Practice Address - Phone:406-237-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT43199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant