Provider Demographics
NPI:1841411709
Name:PETERS, JACOB KENNETH (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:KENNETH
Last Name:PETERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1088
Mailing Address - Street 2:
Mailing Address - City:REEDLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93654
Mailing Address - Country:US
Mailing Address - Phone:559-637-9818
Mailing Address - Fax:559-637-9910
Practice Address - Street 1:750 G STREET
Practice Address - Street 2:
Practice Address - City:REEDLEY
Practice Address - State:CA
Practice Address - Zip Code:93654
Practice Address - Country:US
Practice Address - Phone:559-637-9818
Practice Address - Fax:559-637-9910
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33404207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G334041Medicaid
CA00G334040Medicare PIN
CAA45534Medicare UPIN