Provider Demographics
NPI:1831256577
Name:PETERSON, JAMIE (LCSW)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
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 1:2171 SPRING VIEW CT
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-2476
Mailing Address - Country:US
Mailing Address - Phone:209-834-2690
Mailing Address - Fax:209-523-1296
Practice Address - Street 1:1660 W LINNE RD
Practice Address - Street 2:STE J
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-8024
Practice Address - Country:US
Practice Address - Phone:209-923-7083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS228801041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical