Provider Demographics
NPI:1124500061
Name:PETERSON, JAMIE ANNE (CCC SLP)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:ANNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 SCHOOLVIEW RD
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NY
Mailing Address - Zip Code:14057-1107
Mailing Address - Country:US
Mailing Address - Phone:716-992-3645
Mailing Address - Fax:
Practice Address - Street 1:3000 SCHOOLVIEW RD
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NY
Practice Address - Zip Code:14057-1117
Practice Address - Country:US
Practice Address - Phone:716-992-3638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027796-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist