Provider Demographics
NPI:1780969675
Name:PETERSON, JAYSON LEE (MED, LMFT)
Entity type:Individual
Prefix:
First Name:JAYSON
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MED, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:492 E 13TH AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4250
Mailing Address - Country:US
Mailing Address - Phone:541-579-9288
Mailing Address - Fax:
Practice Address - Street 1:492 E 13TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401
Practice Address - Country:US
Practice Address - Phone:541-579-9288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-11
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT1229106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist