Provider Demographics
NPI:1710607528
Name:PETERSEN, JEANIE ELIZABETH
Entity Type:Individual
Prefix:
First Name:JEANIE
Middle Name:ELIZABETH
Last Name:PETERSEN
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 1:2906 BLUEGRASS WAY
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-2309
Mailing Address - Country:US
Mailing Address - Phone:503-351-5681
Mailing Address - Fax:
Practice Address - Street 1:2906 BLUEGRASS WAY
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-2309
Practice Address - Country:US
Practice Address - Phone:503-351-5681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL10678101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty