Basic Information
| Provider Information | |||||||||
| NPI: | 1629151428 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEDERSEN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14402 E SPRAGUE AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992162167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099222625 | ||||||||
| FaxNumber: | 5099224001 | ||||||||
| Practice Location | |||||||||
| Address1: | 14402 E SPRAGUE AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992162167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099222625 | ||||||||
| FaxNumber: | 5099224001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | O221 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OP00001642 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 129223 | 01 | WA | WA LABOR & INDUSTRIES | OTHER | S3143 | 01 | ID | BLUE CROSS | OTHER | 000010005518 | 01 | ID | REGENCE BLUESHIELD | OTHER | 1043078 | 05 | WA | MEDICAID | 805453200 | 05 | ID | MEDICAID | 1301819 | 01 | ID | DMERC | OTHER | 805453200 | 01 | ID | HEALTHY CONNECTIONS | OTHER |