Healthcare Provider Details

I. General information

NPI: 1760734032
Provider Name (Legal Business Name): JENYFFER PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 MONTANA DEL LAGO DR
RANCHO SANTA MARGARITA CA
92688-1361
US

IV. Provider business mailing address

235 MONTANA DEL LAGO DR
RANCHO SANTA MARGARITA CA
92688-1361
US

V. Phone/Fax

Practice location:
  • Phone: 949-394-4049
  • Fax:
Mailing address:
  • Phone: 949-394-4049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY28968
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: