Basic Information
| Provider Information | |||||||||
| NPI: | 1669865325 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON-JAY | ||||||||
| FirstName: | EBONY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 770 WOODLANE ROAD | ||||||||
| Address2: | |||||||||
| City: | MT. HOLLY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092675928 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2051 SPRINGDALE RD | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080031603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562543800 | ||||||||
| FaxNumber: | 8568740293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2015 | ||||||||
| LastUpdateDate: | 03/05/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.