=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144732918
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIE MICHELLE PETERSON PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2017
-----------------------------------------------------
Last Update Date | 05/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14743 NW GLACIER LN
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97006-5892
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-443-8339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14743 NW GLACIER LN
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97006-5892
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-443-8339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 201808713NP-PP
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------