Provider Demographics
NPI:1649598228
Name:PETERS, JENNIFER RAE (MA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:PETERS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E LUVERNE ST
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:MN
Mailing Address - Zip Code:56158-2006
Mailing Address - Country:US
Mailing Address - Phone:612-655-7966
Mailing Address - Fax:
Practice Address - Street 1:1024 7TH AVE
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-2287
Practice Address - Country:US
Practice Address - Phone:507-329-5087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00139101YM0800X
SDLPC1184101YP2500X
SDLPC-MH2198101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional