Individual
JILL PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
6125 N SUNSHINE ST, COEUR D ALENE, ID 83815
(208) 964-4457
Mailing address
213 E MILES AVE, HAYDEN, ID 83835-8204
(208) 964-4457
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
MA 60093876
WA
Other
Enumeration date
06/15/2010
Last updated
06/15/2010
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