Provider Demographics
NPI:1902526833
Name:PETERSON, JENNIFER ELAINE (LPC)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ELAINE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12857 N ANDYS GULCH RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-9423
Mailing Address - Country:US
Mailing Address - Phone:208-401-4786
Mailing Address - Fax:
Practice Address - Street 1:12857 N ANDYS GULCH RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-9423
Practice Address - Country:US
Practice Address - Phone:208-401-4786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-9027101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional