Provider Demographics
NPI:1760967848
Name:PETERSON, JAIME
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA, CDP
Mailing Address - Street 1:3710 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-2850
Mailing Address - Country:US
Mailing Address - Phone:509-328-5234
Mailing Address - Fax:
Practice Address - Street 1:3710 N MONROE ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-2850
Practice Address - Country:US
Practice Address - Phone:509-328-5234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00006388101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA32035100Medicaid