Provider Demographics
NPI:1992825244
Name:PETERSON, JASON D (DC)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:D
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 1:700 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3504
Mailing Address - Country:US
Mailing Address - Phone:320-231-1414
Mailing Address - Fax:320-231-2828
Practice Address - Street 1:700 1ST ST S
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3504
Practice Address - Country:US
Practice Address - Phone:320-231-1414
Practice Address - Fax:320-231-2828
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3352111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN31B85PEOtherBLUECROSSBLUESHIELD
MN31B85PEOtherBLUECROSSBLUESHIELD