Provider Demographics
NPI:1710043211
Name:PETERSON, J. (PHD, LLC)
Entity Type:Individual
Prefix:
First Name:J.
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHD, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1650
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25443-1650
Mailing Address - Country:US
Mailing Address - Phone:304-876-3766
Mailing Address - Fax:304-876-8431
Practice Address - Street 1:129 EAST GERMAN STREET
Practice Address - Street 2:ROOM 210
Practice Address - City:SHEPHERDSTOWN
Practice Address - State:WV
Practice Address - Zip Code:25443-1650
Practice Address - Country:US
Practice Address - Phone:304-876-3766
Practice Address - Fax:304-876-8431
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV741103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9480075000Medicaid
WVCP23461Medicare PIN