Provider Demographics
NPI:1265197107
Name:PETERSON, JORDAN (DC)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S83W27690 BEAVER TRL
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-9662
Mailing Address - Country:US
Mailing Address - Phone:815-814-4841
Mailing Address - Fax:
Practice Address - Street 1:S83W27690 BEAVER TRL
Practice Address - Street 2:
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-9662
Practice Address - Country:US
Practice Address - Phone:815-814-4841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2110111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor