MEDICARE: DR. JEANNE PETERSON PH.D.

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	103T00000X	Psychologist	PSY14612	CA

General Provider Information

NPI Number	:	1114075397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEANNE PETERSON PH.D.

Provider Business Mailing Address
First Line	:	2752 B ST UNIT 112
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92102-1091
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2752 B ST UNIT 112
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92102-1091
Country	:	US
Telephone Number	:	619-952-8076
Fax Number	:

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

Provider Enumeration Date	:	01/06/2007
Last Update Date	:	06/21/2013

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