Provider Demographics
NPI:1528168382
Name:PETERSEN, HOWARD GALE (DC)
Entity type:Individual
Prefix:
First Name:HOWARD
Middle Name:GALE
Last Name:PETERSEN
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 1:807 E JACKSON BLVD
Mailing Address - Street 2:SUITE TWO
Mailing Address - City:JONESBOROUGH
Mailing Address - State:TN
Mailing Address - Zip Code:37659-1507
Mailing Address - Country:US
Mailing Address - Phone:423-753-4964
Mailing Address - Fax:423-753-4121
Practice Address - Street 1:807 E JACKSON BLVD
Practice Address - Street 2:SUITE TWO
Practice Address - City:JONESBOROUGH
Practice Address - State:TN
Practice Address - Zip Code:37659-1507
Practice Address - Country:US
Practice Address - Phone:423-753-4964
Practice Address - Fax:423-753-4121
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1759111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4100327OtherBCBS
TN3971212Medicaid
TN4100327OtherBCBS
TN3971212Medicare ID - Type Unspecified