Provider Demographics
NPI:1053421628
Name:PETERS, JON
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:PETERS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JON
Other - Middle Name:
Other - Last Name:PETERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:19 BELMONT AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-7109
Mailing Address - Country:US
Mailing Address - Phone:802-257-7106
Mailing Address - Fax:802-257-2270
Practice Address - Street 1:19 BELMONT AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-7109
Practice Address - Country:US
Practice Address - Phone:802-257-7106
Practice Address - Fax:802-257-2270
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT4468247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9897Medicaid