Provider Demographics
NPI:1447648274
Name:PETERSON, JESSICA R (PTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 W 84TH AVE
Mailing Address - Street 2:APT 2828
Mailing Address - City:FEDERAL HEIGHTS
Mailing Address - State:CO
Mailing Address - Zip Code:80260-4725
Mailing Address - Country:US
Mailing Address - Phone:630-750-6876
Mailing Address - Fax:
Practice Address - Street 1:555 S PIERCE ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-3470
Practice Address - Country:US
Practice Address - Phone:303-872-7427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-01
Last Update Date:2015-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13354225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant