Basic Information
Provider Information
NPI: 1003008525
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PETERSON
FirstName: JONATHON
MiddleName: R
NamePrefix:  
NameSuffix:  
Credential: PT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1702 UNIVERSITY DR S
Address2:  
City: FARGO
State: ND
PostalCode: 581034940
CountryCode: US
TelephoneNumber: (701) 364-4222
FaxNumber:  
Practice Location
Address1: 705 PLEASANT AVE S
Address2:  
City: PARK RAPIDS
State: MN
PostalCode: 564701440
CountryCode: US
TelephoneNumber: 2187322800
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/17/2007
LastUpdateDate: 03/17/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X1585NDY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 
225100000X7998MNN Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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