Provider Demographics
NPI:1063174597
Name:PETERSON, JASON L (APRN)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:M
Credentials:APRN
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 220
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:NE
Mailing Address - Zip Code:68333-0220
Mailing Address - Country:US
Mailing Address - Phone:402-826-2102
Mailing Address - Fax:
Practice Address - Street 1:2910 BETTEN DR
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:NE
Practice Address - Zip Code:68333-3084
Practice Address - Country:US
Practice Address - Phone:402-826-2102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE113843363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily