MEDICARE: JULIE M. PETERSON PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN00138549	WA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP60559831	WA
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	201403887NP-PP	OR

General Provider Information

NPI Number	:	1801202528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE M. PETERSON PMHNP

Provider Business Mailing Address
First Line	:	30 NE MLK JR BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97232-2941
Country	:	US
Telephone Number	:	503-232-1099
Fax Number	:	503-232-3854

Provider Business Practice Location Address
First Line	:	30 NE MLK JR BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97232-2941
Country	:	US
Telephone Number	:	503-232-1099
Fax Number	:	503-232-3854

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2014
Last Update Date	:	10/24/2025

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