Provider Demographics
NPI:1952979163
Name:PETERSEN, JORDAN JAMES (DO)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:JAMES
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6905
Mailing Address - Country:US
Mailing Address - Phone:208-521-4408
Mailing Address - Fax:
Practice Address - Street 1:10000 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3330
Practice Address - Country:US
Practice Address - Phone:313-295-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151015319208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation