Provider Demographics
NPI:1043758378
Name:PETERSON, JEREMY THOMAS (DPT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:THOMAS
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:104A HUFFMAN MILL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5113
Practice Address - Country:US
Practice Address - Phone:336-270-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP16865225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist