Provider Demographics
NPI:1104571256
Name:PETERSON, JESSE ROBERT (DPT)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:ROBERT
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 E SPAULDING AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2208
Mailing Address - Country:US
Mailing Address - Phone:719-542-4444
Mailing Address - Fax:719-543-1990
Practice Address - Street 1:3525 E SPAULDING AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2208
Practice Address - Country:US
Practice Address - Phone:719-542-4444
Practice Address - Fax:719-543-1990
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0018220225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist