Provider Demographics
NPI:1023269057
Name:PETERSON, JANELLE ELISE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JANELLE
Middle Name:ELISE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JANELLE
Other - Middle Name:ELISE
Other - Last Name:THOMPSON GOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:913 NW GARDEN VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6523
Mailing Address - Country:US
Mailing Address - Phone:541-440-1000
Mailing Address - Fax:541-440-1356
Practice Address - Street 1:913 NW GARDEN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-6523
Practice Address - Country:US
Practice Address - Phone:541-440-1000
Practice Address - Fax:541-440-1356
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL47421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR090450Medicaid
OR165772Medicaid