Basic Information
| Provider Information | |||||||||
| NPI: | 1457996910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | FREDERICK | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22040 | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543052040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204457222 | ||||||||
| FaxNumber: | 9204457289 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 E SAINT JOSEPH ST | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543012241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204336073 | ||||||||
| FaxNumber: | 9204310333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2019 | ||||||||
| LastUpdateDate: | 11/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 3690-57 | WI | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.