MEDICARE: JEANETTE FAY PELTOLA PLC,MA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	6401003877	MI
2	101Y00000X	Counselor	6401003877	MI

General Provider Information

NPI Number	:	1033720321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANETTE FAY PELTOLA PLC,MA

Provider Business Mailing Address
First Line	:	968 HARBOR CT
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49685-9355
Country	:	US
Telephone Number	:	231-632-1370
Fax Number	:

Provider Business Practice Location Address
First Line	:	968 HARBOR CT
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49685-9355
Country	:	US
Telephone Number	:	231-632-1370
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2020
Last Update Date	:	08/08/2022

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