Provider Demographics
NPI:1699555243
Name:PETERSEN, JESSICA LYNETTE (LIMHP, LMHP, CMSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNETTE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LIMHP, LMHP, CMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11204 DAVENPORT ST STE 200
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-2658
Mailing Address - Country:US
Mailing Address - Phone:402-327-1444
Mailing Address - Fax:
Practice Address - Street 1:11204 DAVENPORT ST STE 200
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-2658
Practice Address - Country:US
Practice Address - Phone:402-356-3332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE22461041C0700X
NE2846104100000X
NE3326101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health