Provider Demographics
NPI:1154876902
Name:PETERSON, JENELE (DPT)
Entity type:Individual
Prefix:
First Name:JENELE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
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:PO BOX 950
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-0950
Mailing Address - Country:US
Mailing Address - Phone:415-898-1311
Mailing Address - Fax:415-897-0741
Practice Address - Street 1:88 ROWLAND WAY
Practice Address - Street 2:SUITE 250
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5042
Practice Address - Country:US
Practice Address - Phone:415-898-1311
Practice Address - Fax:415-897-0741
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT2918752251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic