Provider Demographics
NPI:1669695136
Name:PETERSON, JILL M (PSYD)
Entity type:Individual
Prefix:DR
First Name:JILL
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-2147
Mailing Address - Country:US
Mailing Address - Phone:262-687-8538
Mailing Address - Fax:262-687-4334
Practice Address - Street 1:3801 SPRING ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1667
Practice Address - Country:US
Practice Address - Phone:262-687-8538
Practice Address - Fax:262-687-4334
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2709057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical