Provider Demographics
NPI:1528313269
Name:JONATHAN J. PETERSON, PLLC
Entity type:Organization
Organization Name:JONATHAN J. PETERSON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-208-3835
Mailing Address - Street 1:455 E. SADDLE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143
Mailing Address - Country:US
Mailing Address - Phone:480-208-3835
Mailing Address - Fax:
Practice Address - Street 1:3076 E. CHANDLER HEIGHTS RD.
Practice Address - Street 2:SUITE 107
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298
Practice Address - Country:US
Practice Address - Phone:480-840-3663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7814111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ116226Medicare PIN