Provider Demographics
NPI:1851580658
Name:PETERSON, JODI SANDRA (LIC PROF COUNSELOR)
Entity Type:Individual
Prefix:MRS
First Name:JODI
Middle Name:SANDRA
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LIC PROF COUNSELOR
Other - Prefix:MS
Other - First Name:JODI
Other - Middle Name:SANDRA
Other - Last Name:KEYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LIC PROF COUNSELOR
Mailing Address - Street 1:47 TOWN ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2323
Mailing Address - Country:US
Mailing Address - Phone:860-892-7042
Mailing Address - Fax:860-444-8776
Practice Address - Street 1:47 TOWN ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2323
Practice Address - Country:US
Practice Address - Phone:860-892-7042
Practice Address - Fax:860-892-7043
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001529101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional