Provider Demographics
NPI:1487078911
Name:PETERSON, JAMIE BROOKE (PA-C)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:BROOKE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 NE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1358
Mailing Address - Country:US
Mailing Address - Phone:541-460-5331
Mailing Address - Fax:541-460-5165
Practice Address - Street 1:10394 W HENRYS LAKE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-6283
Practice Address - Country:US
Practice Address - Phone:208-440-0255
Practice Address - Fax:208-231-3371
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-04
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1236363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty