Healthcare Provider Details

I. General information

NPI: 1073762373
Provider Name (Legal Business Name): JAMIE-LYNN PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1827 ATLANTA AVE STE. D-1
RIVERSIDE CA
92507-7419
US

IV. Provider business mailing address

1827 ATLANTA AVE STE. D-1
RIVERSIDE CA
92507-7419
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-2105
  • Fax:
Mailing address:
  • Phone: 951-955-2105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: