Individual
JEDIDIAH ALLEN PETERSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
6 13TH AVE E, POLSON, MT 59860-5315
(406) 883-5680
(406) 883-8960
Mailing address
PO BOX 262, LIBERTY LAKE, WA 99019-0262
(208) 232-7862
(208) 232-7869
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA-1110
ID
Other
Enumeration date
10/30/2013
Last updated
12/08/2015
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