Provider Demographics
NPI:1508338229
Name:PETERS, JESSICA BLAIR (MA, LPC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BLAIR
Last Name:PETERS
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41800 W 11 MILE RD STE 110
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1818
Mailing Address - Country:US
Mailing Address - Phone:947-219-1283
Mailing Address - Fax:
Practice Address - Street 1:41800 W 11 MILE RD STE 110
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1818
Practice Address - Country:US
Practice Address - Phone:947-219-1283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016415101YP2500X
MI6401018211101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional