Provider Demographics
NPI:1295804193
Name:PETERSON, JEAN B (LCSW)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:B
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 GODFREY ST
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-1702
Mailing Address - Country:US
Mailing Address - Phone:860-536-4478
Mailing Address - Fax:860-536-4478
Practice Address - Street 1:22 BAYVIEW AVE
Practice Address - Street 2:
Practice Address - City:STONINGTON
Practice Address - State:CT
Practice Address - Zip Code:06378-1142
Practice Address - Country:US
Practice Address - Phone:860-536-4478
Practice Address - Fax:860-536-4478
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0037351041C0700X
NYR010111-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT800003463Medicare ID - Type Unspecified
NYN20421Medicare PIN