=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902164155
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JONATHAN G. PETERSON PSYCHIATRY, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2012
-----------------------------------------------------
Last Update Date | 05/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 HIAWATHA DR E
-----------------------------------------------------
City | WABASHA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55981-1552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-564-1545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 266
-----------------------------------------------------
City | WABASHA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55981-0266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-564-1545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JONATHAN G PETERSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 651-564-1545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 33320
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------