Provider Demographics
NPI:1356343834
Name:PETERSEN, PATRICIA JEAN (LISW)
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:JEAN
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8859 NW 67TH CT
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-1900
Mailing Address - Country:US
Mailing Address - Phone:515-251-4914
Mailing Address - Fax:
Practice Address - Street 1:5525 MEREDITH DR
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-2334
Practice Address - Country:US
Practice Address - Phone:515-251-4914
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
IA059241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical