Provider Demographics
NPI:1780384081
Name:PETERSON-KOSTALEK, JENNIFER ANN (BHT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:PETERSON-KOSTALEK
Suffix:
Gender:F
Credentials:BHT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:312 N ALMA SCHOOL RD STE 11
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-4354
Mailing Address - Country:US
Mailing Address - Phone:623-300-5477
Mailing Address - Fax:
Practice Address - Street 1:312 N ALMA SCHOOL RD STE 11
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-4354
Practice Address - Country:US
Practice Address - Phone:623-300-5477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician