Provider Demographics
NPI:1609930932
Name:LIFE JOURNEY PSYCHIATRIC PLLC
Entity Type:Organization
Organization Name:LIFE JOURNEY PSYCHIATRIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LANA
Authorized Official - Middle Name:JEANETTE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, PSYNP
Authorized Official - Phone:480-221-5532
Mailing Address - Street 1:3655 E. BLUEBIRD PLACE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85249
Mailing Address - Country:US
Mailing Address - Phone:480-221-5532
Mailing Address - Fax:480-726-3795
Practice Address - Street 1:3655 E. BLUEBIRD PLACE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85249
Practice Address - Country:US
Practice Address - Phone:480-221-5532
Practice Address - Fax:480-726-3795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN089291363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ787757Medicaid
AZP90736Medicare UPIN
AZ787757Medicaid
AZ108799Medicare ID - Type Unspecified