Provider Demographics
NPI:1144732918
Name:PETERSON, JENNIE MICHELLE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:MICHELLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14743 NW GLACIER LN
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-5892
Mailing Address - Country:US
Mailing Address - Phone:503-443-8339
Mailing Address - Fax:
Practice Address - Street 1:14743 NW GLACIER LN
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-5892
Practice Address - Country:US
Practice Address - Phone:503-443-8339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201808713NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health