Provider Demographics
NPI:1831735141
Name:PETERSEN, JON WALTER (LPC)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:WALTER
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4136 QUEEN AVE S APT 100
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1254
Mailing Address - Country:US
Mailing Address - Phone:952-564-7365
Mailing Address - Fax:
Practice Address - Street 1:4136 QUEEN AVE S APT 100
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55410-1254
Practice Address - Country:US
Practice Address - Phone:952-564-7365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor