Basic Information
| Provider Information | |||||||||
| NPI: | 1669553723 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4804 SUNSET BEACH DRIVE NW | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608670595 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1213 24TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | ANACORTES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982212595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602933101 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 01/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OP00001517 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | A1820 | 01 | PREMERA HEALTH | OTHER | BP4916740 | 01 | DEA | OTHER | 3568326 | 01 | AETNA HMO | OTHER | 50D1031645 | 01 | CLIA | OTHER | OP00001517 | 01 | WA STATE LICENSE | OTHER | 601371600 | 01 | US DEPT OF LABOR | OTHER | A1825 | 01 | PREMERA LIFEWISE | OTHER | 8192247 | 01 | DSHS | OTHER | A1820 | 01 | PREMERA DIMENSIONS | OTHER | O186018 | 01 | L & I | OTHER | 2007PE | 01 | BLUESHIELD FEDERAL | OTHER | 2007PE | 01 | REGENCE BLUESHIELD | OTHER | 5617199 | 01 | AETNA NON HMO | OTHER | A1820 | 01 | PREMERA BLUE CROSS | OTHER |