Provider Demographics
NPI:1891236550
Name:PETERSEN, JENNIFER (MA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PETERSEN
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 1:103 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-1204
Mailing Address - Country:US
Mailing Address - Phone:574-268-0448
Mailing Address - Fax:
Practice Address - Street 1:103 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-1204
Practice Address - Country:US
Practice Address - Phone:574-268-0448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor