Provider Demographics
NPI:1457824245
Name:PETERSON, JAMIE LYN
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYN
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 1:4271 ROXBURY DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7632
Mailing Address - Country:US
Mailing Address - Phone:716-533-0136
Mailing Address - Fax:
Practice Address - Street 1:70 JEWETT PKWY
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2322
Practice Address - Country:US
Practice Address - Phone:716-328-8937
Practice Address - Fax:716-533-4301
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006613-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006613-1OtherUNIVERSITY OF STATE OF NEW YORK EDUCATION DEPARTMENT