Healthcare Provider Details

I. General information

NPI: 1285327841
Provider Name (Legal Business Name): JARED M. PETERSEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 S ZINTEL WAY STE 110
KENNEWICK WA
99337-5044
US

IV. Provider business mailing address

550 GAGE BLVD STE 101
RICHLAND WA
99352-9532
US

V. Phone/Fax

Practice location:
  • Phone: 509-942-3125
  • Fax: 509-585-8173
Mailing address:
  • Phone: 509-946-4611
  • Fax: 509-627-2983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO.OP.70107140
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: