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General NPI Number Information
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NPI Number | 1124650171
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Entity Type | Individual
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Provider Name | JORDAN PETERSON
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Gender | Female
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Dates
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Enumeration Date | 02/07/2020
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Last Update Date | 11/18/2024
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Provider Practice Location Address
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Address Line | 9520 PADGETT ST
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City | SAN DIEGO
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State | CA
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Zip | 92126-4445
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Country | US
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Telephone | 858-866-8133
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Fax |
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Provider Business Mailing Address
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Address Line | 3544 CAMINITO EL RINCON UNIT 51
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City | SAN DIEGO
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State | CA
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Zip | 92130-2549
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Country | US
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Telephone | 715-410-4077
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2251P0200X
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Taxonomy Name | Pediatric Physical Therapist
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License Number | 306141
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License Number State | CA
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