Provider Demographics
NPI:1407433006
Name:PETERSON, JANETTE SUSAN
Entity Type:Individual
Prefix:
First Name:JANETTE
Middle Name:SUSAN
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:PO BOX 58
Mailing Address - Street 2:
Mailing Address - City:LEADORE
Mailing Address - State:ID
Mailing Address - Zip Code:83464-0058
Mailing Address - Country:US
Mailing Address - Phone:208-303-0307
Mailing Address - Fax:
Practice Address - Street 1:27 HARVEY LN
Practice Address - Street 2:
Practice Address - City:LEADORE
Practice Address - State:ID
Practice Address - Zip Code:83464-5035
Practice Address - Country:US
Practice Address - Phone:208-303-0307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-28
Last Update Date:2021-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000641145103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool