Provider Demographics
NPI:1962491621
Name:PETERSON, JEFFERY J (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11707 CLUB DR
Mailing Address - Street 2:TAMPA MHBS CLINIC / OPC
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-5521
Mailing Address - Country:US
Mailing Address - Phone:813-631-7121
Mailing Address - Fax:
Practice Address - Street 1:11707 CLUB DR
Practice Address - Street 2:TAMPA MHBS CLINIC / OPC
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-5521
Practice Address - Country:US
Practice Address - Phone:813-631-7121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1307103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling