Provider Demographics
NPI:1235771429
Name:PETERSON, JENNIFER (LMFT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 STEARNS WAY STE 111
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1275
Mailing Address - Country:US
Mailing Address - Phone:320-253-3540
Mailing Address - Fax:
Practice Address - Street 1:2025 STEARNS WAY STE 111
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1275
Practice Address - Country:US
Practice Address - Phone:320-253-3540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3807106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist