Provider Demographics
NPI:1285990002
Name:PETERSON COUNSELING AND SUPERVISION, LLC
Entity type:Organization
Organization Name:PETERSON COUNSELING AND SUPERVISION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:952-808-6848
Mailing Address - Street 1:1585 THOMAS CENTER DR
Mailing Address - Street 2:104
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-3007
Mailing Address - Country:US
Mailing Address - Phone:952-808-6848
Mailing Address - Fax:
Practice Address - Street 1:1585 THOMAS CENTER DR
Practice Address - Street 2:104
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3007
Practice Address - Country:US
Practice Address - Phone:952-808-6848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20365251S00000X
MN20366251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN06202Medicaid