MEDICARE: MS. JATIA PETERSON LMSW

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	104100000X	Social Worker	088378	NY

General Provider Information

NPI Number	:	1972840114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JATIA PETERSON LMSW

Provider Business Mailing Address
First Line	:	620 ERIE BLVD W
Second Line	:	SUITE 208
City	:	SYRACUSE
State	:	NY
Zip	:	13204-2445
Country	:	US
Telephone Number	:	315-472-7363
Fax Number	:

Provider Business Practice Location Address
First Line	:	620 ERIE BLVD W
Second Line	:	SUITE 208
City	:	SYRACUSE
State	:	NY
Zip	:	13204-2445
Country	:	US
Telephone Number	:	315-472-7363
Fax Number	:

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

Provider Enumeration Date	:	01/08/2013
Last Update Date	:	03/16/2016

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