Provider Demographics
NPI:1881167633
Name:PETERSON, JAMES TIMOTHY (MS, LCGC)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:TIMOTHY
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MS, LCGC
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, LCGC
Mailing Address - Street 1:MITOCHONDRIAL MEDICINE FRONTIER PROGRAM- 10TH FLOOR ARC
Mailing Address - Street 2:3615 CIVIC CENTER BLVD
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3615 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4318
Practice Address - Country:US
Practice Address - Phone:267-426-4961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA000488170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS