Provider Demographics
NPI:1265958748
Name:PETERSON, JAMES JERRY III (BA)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:JERRY
Last Name:PETERSON
Suffix:III
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2138 BLACKWOLF RUN LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-5411
Mailing Address - Country:US
Mailing Address - Phone:916-627-5859
Mailing Address - Fax:
Practice Address - Street 1:2138 BLACKWOLF RUN LN
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-5411
Practice Address - Country:US
Practice Address - Phone:916-627-5859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst