1124180104 NPI number — DR. JENNIFER JILL PETERSEN D.C.

Table of content: DR. JENNIFER JILL PETERSEN D.C. (NPI 1124180104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124180104 NPI number — DR. JENNIFER JILL PETERSEN D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSEN
Provider First Name:
JENNIFER
Provider Middle Name:
JILL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124180104
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 154
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55044-0154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-469-6016
Provider Business Mailing Address Fax Number:
952-469-4017

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20730 HOLYOKE AVE
Provider Second Line Business Practice Location Address:
SUITE 34
Provider Business Practice Location Address City Name:
LAKEVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-469-6016
Provider Business Practice Location Address Fax Number:
952-469-4017
Provider Enumeration Date:
12/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3661 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com