Healthcare Provider Details

I. General information

NPI: 1710043211
Provider Name (Legal Business Name): J. PETERSON PH.D., L.L.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 EAST GERMAN STREET ROOM 210
SHEPHERDSTOWN WV
25443-1650
US

IV. Provider business mailing address

PO BOX 1650
SHEPHERDSTOWN WV
25443-1650
US

V. Phone/Fax

Practice location:
  • Phone: 304-876-3766
  • Fax: 304-876-8431
Mailing address:
  • Phone: 304-876-3766
  • Fax: 304-876-8431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number741
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: