Provider Demographics
NPI:1497966238
Name:PETERSON, JESSICA ANN (LICSW, CSW-PIP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ANN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LICSW, CSW-PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6485 134TH ST W
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7917
Mailing Address - Country:US
Mailing Address - Phone:952-303-1856
Mailing Address - Fax:
Practice Address - Street 1:1585 THOMAS CENTER DR
Practice Address - Street 2:STE 104
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3039
Practice Address - Country:US
Practice Address - Phone:763-560-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND45501041C0700X
SD30281041C0700X
MN203651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical