Provider Demographics
NPI:1760734032
Name:PETERSON, JENYFFER
Entity Type:Individual
Prefix:
First Name:JENYFFER
Middle Name:
Last Name:PETERSON
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 1:447 N EL MOLINO AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1403
Mailing Address - Country:US
Mailing Address - Phone:626-577-8480
Mailing Address - Fax:626-577-8978
Practice Address - Street 1:3939 ATLANTIC AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3536
Practice Address - Country:US
Practice Address - Phone:562-264-6001
Practice Address - Fax:562-264-6006
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28968103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical