MEDICARE: JILL C. PETERSON LLC

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	103TC0700X	Clinical Psychologist	946	HI

General Provider Information

NPI Number	:	1427392950
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JILL C. PETERSON LLC

Provider Business Mailing Address
First Line	:	1759 IWI WAY
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96816-3826
Country	:	US
Telephone Number	:	808-721-8048
Fax Number	:	808-394-2826

Provider Business Practice Location Address
First Line	:	6600 KALANIANAOLE HWY
Second Line	:	SUITE 225
City	:	HONOLULU
State	:	HI
Zip	:	96825-1273
Country	:	US
Telephone Number	:	808-721-8048
Fax Number	:	808-394-2826

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JILL C PETERSON
Credential	:	PSY.D.
Telephone Number	:	808-721-8048

Provider Enumeration Date	:	11/21/2012
Last Update Date	:	11/21/2012

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