MEDICARE: MS. JENNIFER PELTON 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	103TC2200X	Clinical Child & Adolescent Psychologist	PY00003112	WA

General Provider Information

NPI Number	:	1255437810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNIFER PELTON PH.D.

Provider Business Mailing Address
First Line	:	2910 E MADISON ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98112-4214
Country	:	US
Telephone Number	:	206-729-2829
Fax Number	:

Provider Business Practice Location Address
First Line	:	2910 E MADISON ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98112-4214
Country	:	US
Telephone Number	:	206-729-2829
Fax Number	:

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

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	07/08/2007

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