Provider Demographics
NPI:1417145079
Name:JEANNE M. PETERSON, PH.D., PSYCHOLOGIST, INC.
Entity Type:Organization
Organization Name:JEANNE M. PETERSON, PH.D., PSYCHOLOGIST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:619-952-8076
Mailing Address - Street 1:2752 B ST UNIT 112
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-1091
Mailing Address - Country:US
Mailing Address - Phone:619-952-8076
Mailing Address - Fax:
Practice Address - Street 1:2752 B ST UNIT 112
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-1091
Practice Address - Country:US
Practice Address - Phone:619-952-8076
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14612A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GW862AMedicare PIN
CP14612AMedicare PIN