Provider Demographics
NPI:1528411139
Name:PETERSON, JANAE (ACMHC)
Entity Type:Individual
Prefix:MS
First Name:JANAE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 E 930 S
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-3635
Mailing Address - Country:US
Mailing Address - Phone:801-601-9107
Mailing Address - Fax:
Practice Address - Street 1:595 E 930 S
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-3635
Practice Address - Country:US
Practice Address - Phone:801-601-9107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8743664-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health