Healthcare Provider Details

I. General information

NPI: 1104571256
Provider Name (Legal Business Name): JESSE ROBERT PETERSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2022
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3327 RESEARCH PLZ STE 215
SAN ANTONIO TX
78235-5157
US

IV. Provider business mailing address

400 CONCORD PLAZA DR STE 300
SAN ANTONIO TX
78216-6991
US

V. Phone/Fax

Practice location:
  • Phone: 210-804-5400
  • Fax:
Mailing address:
  • Phone: 210-804-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License Number1408526
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: