1396983128 NPI number — JON PETERSON PSYCHOLOGIST PHD PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396983128 NPI number — JON PETERSON PSYCHOLOGIST PHD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JON PETERSON PSYCHOLOGIST PHD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396983128
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25401 CABOT RD
Provider Second Line Business Mailing Address:
SUITE 213
Provider Business Mailing Address City Name:
LAGUNA HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92653-5524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-363-7386
Provider Business Mailing Address Fax Number:
949-276-2199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25401 CABOT RD
Provider Second Line Business Practice Location Address:
SUITE 213
Provider Business Practice Location Address City Name:
LAGUNA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92653-5524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-363-7386
Provider Business Practice Location Address Fax Number:
949-276-2199
Provider Enumeration Date:
02/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PETERSON
Authorized Official First Name:
JON
Authorized Official Middle Name:
W
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
949-363-7386

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  PSY6987 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com