Provider Demographics
NPI:1003469859
Name:PETERSON, JAIMIE M
Entity Type:Individual
Prefix:
First Name:JAIMIE
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2265 W ALTORFER DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1807
Mailing Address - Country:US
Mailing Address - Phone:309-683-7700
Mailing Address - Fax:309-683-7752
Practice Address - Street 1:2265 W ALTORFER DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1807
Practice Address - Country:US
Practice Address - Phone:309-683-7700
Practice Address - Fax:309-683-7752
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490202041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical