Provider Demographics
NPI:1073928669
Name:PETERS, JACLYN (PHD)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 FOUNDERS BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-6163
Mailing Address - Country:US
Mailing Address - Phone:706-548-8697
Mailing Address - Fax:706-548-8698
Practice Address - Street 1:1090 FOUNDERS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6163
Practice Address - Country:US
Practice Address - Phone:706-548-8697
Practice Address - Fax:706-548-8698
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003796103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist