Provider Demographics
NPI:1487276697
Name:PETERSEN, JERRY THOMAS MATTHEW (MT-BC)
Entity type:Individual
Prefix:
First Name:JERRY THOMAS
Middle Name:MATTHEW
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16620 40TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55446-2687
Mailing Address - Country:US
Mailing Address - Phone:563-249-5781
Mailing Address - Fax:
Practice Address - Street 1:136 SANDBAR CT NE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-2652
Practice Address - Country:US
Practice Address - Phone:763-415-0374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic TherapistGroup - Single Specialty