Provider Demographics
NPI:1831735141
Name:PETERSEN, JON WALTER (MA, MED, LPCC, CMHC)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:WALTER
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MA, MED, LPCC, CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 PARK GLEN RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5427
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-925-8496
Practice Address - Street 1:1155 FORD RD STE B
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-1115
Practice Address - Country:US
Practice Address - Phone:952-378-1800
Practice Address - Fax:952-378-1714
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12348521-6004101YM0800X
MN2463101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health