Provider Demographics
NPI:1194374165
Name:PETERSON, JEANICE (LEP)
Entity Type:Individual
Prefix:
First Name:JEANICE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41914 50TH ST W
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-2963
Mailing Address - Country:US
Mailing Address - Phone:661-722-0716
Mailing Address - Fax:
Practice Address - Street 1:41914 50TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-2963
Practice Address - Country:US
Practice Address - Phone:661-722-0716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3666103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool