Provider Demographics
NPI:1356141592
Name:PETERSON, JADA
Entity type:Individual
Prefix:
First Name:JADA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5837 CALLAWAY CIR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-3237
Mailing Address - Country:US
Mailing Address - Phone:850-252-7123
Mailing Address - Fax:
Practice Address - Street 1:2924 KINGS RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2016
Practice Address - Country:US
Practice Address - Phone:850-248-1057
Practice Address - Fax:850-254-2969
Is Sole Proprietor?:No
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician