Individual
JACOB LOUIS PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
5667 S REDWOOD RD, TAYLORSVILLE, UT 84123-5433
(801) 979-1351
Mailing address
6195 FOX POINTE CIR APT C1, PARK CITY, UT 84098-7597
(208) 629-9680
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1114904646
—
UT
Enumeration date
05/07/2014
Last updated
05/07/2014
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