Provider Demographics
NPI:1760734032
Name:PETERSON, JENYFFER
Entity type:Individual
Prefix:
First Name:JENYFFER
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 MONTANA DEL LAGO DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-1361
Mailing Address - Country:US
Mailing Address - Phone:949-394-4049
Mailing Address - Fax:
Practice Address - Street 1:235 MONTANA DEL LAGO DR
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-1361
Practice Address - Country:US
Practice Address - Phone:949-394-4049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28968103TC0700X
103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging