Provider Demographics
NPI:1073668000
Name:PETERSON, JASON R (R D)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:M
Credentials:R D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:1111 6TH AVE
Practice Address - Street 2:SUITE 510
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-2610
Practice Address - Country:US
Practice Address - Phone:515-643-5275
Practice Address - Fax:515-643-5276
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01563133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal