Provider Demographics
NPI:1609200476
Name:PETERS, JASON RAY (MS, LPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:RAY
Last Name:PETERS
Suffix:
Gender:M
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 W HOVEY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-1511
Mailing Address - Country:US
Mailing Address - Phone:417-827-6547
Mailing Address - Fax:
Practice Address - Street 1:1506 W HOVEY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-1511
Practice Address - Country:US
Practice Address - Phone:417-827-6547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO6482101YA0400X
MO2015031521101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2015031521Medicaid