Provider Demographics
NPI:1518339399
Name:PETERSON, JACQUELINE ALYSE (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ALYSE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 DUNN AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3214
Mailing Address - Country:US
Mailing Address - Phone:307-715-4150
Mailing Address - Fax:
Practice Address - Street 1:2315 DUNN AVE STE 8
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3214
Practice Address - Country:US
Practice Address - Phone:307-715-4150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO099262611041C0700X
WYLCSW-11971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical