Healthcare Provider Details

I. General information

NPI: 1407433006
Provider Name (Legal Business Name): JANETTE SUSAN PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2021
Last Update Date: 03/28/2021
Certification Date: 03/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 HARVEY LN
LEADORE ID
83464-5035
US

IV. Provider business mailing address

PO BOX 58
LEADORE ID
83464-0058
US

V. Phone/Fax

Practice location:
  • Phone: 208-303-0307
  • Fax:
Mailing address:
  • Phone: 208-303-0307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number0000641145
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: