Provider Demographics
NPI:1205626173
Name:PETERSON, JENNA
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 BIELENBERG DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1406
Mailing Address - Country:US
Mailing Address - Phone:612-760-4014
Mailing Address - Fax:
Practice Address - Street 1:748 BIELENBERG DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1406
Practice Address - Country:US
Practice Address - Phone:612-760-4014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst