Provider Demographics
NPI:1104581115
Name:PETERSON, MARY JANE (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:JANE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19742 OLMSTEAD RD NE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:OR
Mailing Address - Zip Code:97002-8712
Mailing Address - Country:US
Mailing Address - Phone:503-678-2338
Mailing Address - Fax:
Practice Address - Street 1:19742 OLMSTEAD RD NE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:OR
Practice Address - Zip Code:97002-8712
Practice Address - Country:US
Practice Address - Phone:503-678-2338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date: