Provider Demographics
NPI:1952543969
Name:PETERSEN, JEFFREY W (ATC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:W
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1604
Mailing Address - Country:US
Mailing Address - Phone:815-432-1005
Mailing Address - Fax:
Practice Address - Street 1:308 S 3RD ST
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1604
Practice Address - Country:US
Practice Address - Phone:815-432-1005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960014262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer