Provider Demographics
NPI:1609360247
Name:PETERSON, JONATHAN C
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:C
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 ANNAPOLIS RD STE B2
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2062
Mailing Address - Country:US
Mailing Address - Phone:301-850-1148
Mailing Address - Fax:866-250-3233
Practice Address - Street 1:9500 ANNAPOLIS RD STE B2
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-2062
Practice Address - Country:US
Practice Address - Phone:301-850-1148
Practice Address - Fax:866-250-3233
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician