Provider Demographics
NPI:1285006684
Name:PETERSON, JUDY PATRICIA
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:PATRICIA
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 1:2425 NIETO WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8577
Mailing Address - Country:US
Mailing Address - Phone:253-255-3046
Mailing Address - Fax:
Practice Address - Street 1:2425 NIETO WAY
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8577
Practice Address - Country:US
Practice Address - Phone:253-255-3046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-24
Last Update Date:2015-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR280341224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant