Provider Demographics
NPI:1700582160
Name:PETERSEN, JESSICA RAELYNN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAELYNN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28682 SE 424TH ST
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-9786
Mailing Address - Country:US
Mailing Address - Phone:253-293-6405
Mailing Address - Fax:
Practice Address - Street 1:27121 174TH PL SE STE 105
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-4939
Practice Address - Country:US
Practice Address - Phone:425-399-3245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty