=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851845408
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA SUE PETERSON LLMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2016
-----------------------------------------------------
Last Update Date | 08/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 508 SHATTUCK RD
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48604-2329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-752-7867
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7360 MONTAGUE ST
-----------------------------------------------------
City | OWENDALE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48754-5133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-550-0290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801099706
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------