MEDICARE: MR. JACOB M PETERS MA

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	101YP2500X	Professional Counselor	12523-125	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12523-125	OTHER	WI	STATE OF WI DSPS

General Provider Information

NPI Number	:	1821874769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACOB M PETERS MA

Provider Business Mailing Address
First Line	:	300 RIP VAN WINKLE DR
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53186-3057
Country	:	US
Telephone Number	:	262-278-0044
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 RIP VAN WINKLE DR
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53186-3057
Country	:	US
Telephone Number	:	262-278-0044
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2023
Last Update Date	:	04/27/2026

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