Provider Demographics
NPI:1063635563
Name:PETERSON, JERALEEN M (LCSW)
Entity Type:Individual
Prefix:
First Name:JERALEEN
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4571
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729-4571
Mailing Address - Country:US
Mailing Address - Phone:909-291-9349
Mailing Address - Fax:888-272-6076
Practice Address - Street 1:10601 CIVIC CENTER DR STE 100L
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3878
Practice Address - Country:US
Practice Address - Phone:909-291-9349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 285611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical