Provider Demographics
NPI:1285713248
Name:PETERSON, JEREMY R (DC)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 PINE LAKE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-6035
Mailing Address - Country:US
Mailing Address - Phone:402-423-5050
Mailing Address - Fax:402-423-5065
Practice Address - Street 1:3200 PINE LAKE RD
Practice Address - Street 2:SUITE B
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-6035
Practice Address - Country:US
Practice Address - Phone:402-423-5050
Practice Address - Fax:402-423-5065
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1372111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025223200Medicaid
278901Medicare ID - Type Unspecified
NE10025223200Medicaid