Healthcare Provider Details

I. General information

NPI: 1952219982
Provider Name (Legal Business Name): GARY JACK PETERSON LAC-23090
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6303 E TANQUE VERDE RD STE 210
TUCSON AZ
85715-3859
US

IV. Provider business mailing address

3732 BARRACO DR
SIERRA VISTA AZ
85650-4208
US

V. Phone/Fax

Practice location:
  • Phone: 520-423-5600
  • Fax: 520-423-5600
Mailing address:
  • Phone:
  • Fax: 520-335-7548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-23090
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: