Provider Demographics
NPI:1093491417
Name:PETERSON, DAVID JORDAN (MS, LAC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JORDAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MS, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 W STONEY BROOK RD APT 9106
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-4649
Mailing Address - Country:US
Mailing Address - Phone:903-571-8955
Mailing Address - Fax:
Practice Address - Street 1:109 N 48TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-3743
Practice Address - Country:US
Practice Address - Phone:479-222-0269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2304006101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health