Provider Demographics
NPI:1194292805
Name:PETERSON, JESSICA MARIE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 718
Mailing Address - Street 2:
Mailing Address - City:SAGAMORE
Mailing Address - State:MA
Mailing Address - Zip Code:02561-0718
Mailing Address - Country:US
Mailing Address - Phone:774-994-2928
Mailing Address - Fax:
Practice Address - Street 1:4 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:SAGAMORE
Practice Address - State:MA
Practice Address - Zip Code:02561-0718
Practice Address - Country:US
Practice Address - Phone:774-994-2928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program