Provider Demographics
NPI:1780820191
Name:PETERSON, JAIMIE LYNETTE (COTA)
Entity Type:Individual
Prefix:
First Name:JAIMIE
Middle Name:LYNETTE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BIITTIG RD
Mailing Address - Street 2:
Mailing Address - City:AVERILL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12018-3003
Mailing Address - Country:US
Mailing Address - Phone:518-674-0367
Mailing Address - Fax:
Practice Address - Street 1:1 RAPP RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-4491
Practice Address - Country:US
Practice Address - Phone:518-867-3061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003145-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant