MEDICARE: PETERSON COUNSELING AND SUPERVISION, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	20366	MN
2	251S00000X	Community/Behavioral Health Agency	20365	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285990002
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETERSON COUNSELING AND SUPERVISION, LLC

Provider Business Mailing Address
First Line	:	1585 THOMAS CENTER DR
Second Line	:	104
City	:	EAGAN
State	:	MN
Zip	:	55122-3007
Country	:	US
Telephone Number	:	952-808-6848
Fax Number	:

Provider Business Practice Location Address
First Line	:	1585 THOMAS CENTER DR
Second Line	:	104
City	:	EAGAN
State	:	MN
Zip	:	55122-3007
Country	:	US
Telephone Number	:	952-808-6848
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	JESSICA ANN PETERSON
Credential	:	LICSW
Telephone Number	:	952-808-6848

Provider Enumeration Date	:	04/05/2012
Last Update Date	:	11/13/2013

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