Provider Demographics
NPI:1033173349
Name:PETERSON, JOLENE (MSW LCSW PIP)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MSW LCSW PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 CANYON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8114
Mailing Address - Country:US
Mailing Address - Phone:605-355-2215
Mailing Address - Fax:605-355-2504
Practice Address - Street 1:3200 CANYON LAKE DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8114
Practice Address - Country:US
Practice Address - Phone:605-355-2215
Practice Address - Fax:605-355-2504
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD12651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD554090Medicaid
SD554090Medicaid
SDQ09441Medicare UPIN