=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841411709
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB KENNETH PETERS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 12/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 G STREET
-----------------------------------------------------
City | REEDLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-637-9818
-----------------------------------------------------
Fax | 559-637-9910
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1088
-----------------------------------------------------
City | REEDLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-637-9818
-----------------------------------------------------
Fax | 559-637-9910
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | G33404
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | G33404
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------