Provider Demographics
NPI:1871515593
Name:PETERSON, JACOB AARON (DC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:AARON
Last Name:PETERSON
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:PO BOX 274
Mailing Address - Street 2:
Mailing Address - City:PITTSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54466-0274
Mailing Address - Country:US
Mailing Address - Phone:715-884-2379
Mailing Address - Fax:715-884-2411
Practice Address - Street 1:434 N STAR RD
Practice Address - Street 2:
Practice Address - City:HOLMEN
Practice Address - State:WI
Practice Address - Zip Code:54636-4402
Practice Address - Country:US
Practice Address - Phone:608-526-3343
Practice Address - Fax:608-526-9366
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4137-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00600196OtherMEDICARE RAILROAD
WI38961300Medicaid
WI38961300Medicaid
WI38961300Medicaid
WIP00600196OtherMEDICARE RAILROAD
WI000570470Medicare PIN