Basic Information
| Provider Information | |||||||||
| NPI: | 1003469859 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | JAIMIE | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2265 W ALTORFER DR | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616151807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096837700 | ||||||||
| FaxNumber: | 3096837752 | ||||||||
| Practice Location | |||||||||
| Address1: | 2265 W ALTORFER DR | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616151807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096837700 | ||||||||
| FaxNumber: | 3096837752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2019 | ||||||||
| LastUpdateDate: | 07/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149020204 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.