Provider Demographics
NPI:1134655574
Name:PETERSON, JENELLE
Entity Type:Individual
Prefix:
First Name:JENELLE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENELLE
Other - Middle Name:
Other - Last Name:KLEINKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2025 COULTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-5302
Mailing Address - Country:US
Mailing Address - Phone:952-522-3132
Mailing Address - Fax:
Practice Address - Street 1:2025 COULTER BLVD
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-5302
Practice Address - Country:US
Practice Address - Phone:952-522-3132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2021-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health