Provider Demographics
NPI:1891992988
Name:J. PETERSON, PH.D., LLC
Entity Type:Organization
Organization Name:J. PETERSON, PH.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:304-876-3766
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:304-876-8631
Practice Address - Street 1:129 EAST GERMAN ST.
Practice Address - Street 2:SUITE 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV741103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9480075000Medicaid
WV9480075000Medicaid
WV9480075000Medicaid