Healthcare Provider Details

I. General information

NPI: 1952979163
Provider Name (Legal Business Name): JORDAN JAMES PETERSEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 06/08/2025
Certification Date: 06/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 E EISENHOWER PKWY
ANN ARBOR MI
48108-3364
US

IV. Provider business mailing address

325 E EISENHOWER PKWY
ANN ARBOR MI
48108-3364
US

V. Phone/Fax

Practice location:
  • Phone: 734-763-6464
  • Fax:
Mailing address:
  • Phone: 734-763-6464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number5101028465
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: