Provider Demographics
NPI:1346480324
Name:PETERSEN, JESSICA RAE (DC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2351
Mailing Address - Country:US
Mailing Address - Phone:708-422-3300
Mailing Address - Fax:708-422-3303
Practice Address - Street 1:5505 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2351
Practice Address - Country:US
Practice Address - Phone:708-422-3300
Practice Address - Fax:708-422-3303
Is Sole Proprietor?:No
Enumeration Date:2009-03-03
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011324111N00000X
IL038.011324111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor