Healthcare Provider Details

I. General information

NPI: 1063174597
Provider Name (Legal Business Name): JASON L PETERSON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 BETTEN DR
CRETE NE
68333-3084
US

IV. Provider business mailing address

PO BOX 220
CRETE NE
68333-0220
US

V. Phone/Fax

Practice location:
  • Phone: 402-826-2102
  • Fax:
Mailing address:
  • Phone: 402-826-2102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number113843
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: