Provider Demographics
NPI:1114149812
Name:PETERSON, JANICE L (PHD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:L
Last Name:PETERSON
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 1:3246 HENDERSON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-7323
Mailing Address - Country:US
Mailing Address - Phone:614-451-0176
Mailing Address - Fax:614-451-8138
Practice Address - Street 1:3246 HENDERSON RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-7323
Practice Address - Country:US
Practice Address - Phone:614-451-0176
Practice Address - Fax:614-451-8138
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5893103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical