Provider Demographics
NPI:1467769190
Name:PENTON, JON MICHAEL (MA, LP)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:MICHAEL
Last Name:PENTON
Suffix:
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 953
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-0953
Mailing Address - Country:US
Mailing Address - Phone:612-701-9255
Mailing Address - Fax:
Practice Address - Street 1:22551 DODGE CT
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-8479
Practice Address - Country:US
Practice Address - Phone:612-701-9255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0749103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical