Provider Demographics
NPI:1962581561
Name:PETERSON, JANIS LYNNE (PHD)
Entity type:Individual
Prefix:DR
First Name:JANIS
Middle Name:LYNNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JANIS
Other - Middle Name:P
Other - Last Name:MAYBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:4700 POINT FOSDICK DR NW
Mailing Address - Street 2:SUITE 302
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1706
Mailing Address - Country:US
Mailing Address - Phone:253-851-3808
Mailing Address - Fax:253-851-3188
Practice Address - Street 1:4700 POINT FOSDICK DR NW
Practice Address - Street 2:SUITE 302
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1706
Practice Address - Country:US
Practice Address - Phone:253-851-3808
Practice Address - Fax:253-851-3188
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1248103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG115000362Medicare ID - Type Unspecified