Healthcare Provider Details

I. General information

NPI: 1558832410
Provider Name (Legal Business Name): JOCELYN PETERSON LMFT, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 FOLKINGHAM LN
BELLA VISTA AR
72715-3042
US

IV. Provider business mailing address

PO BOX 5032
BELLA VISTA AR
72714-0032
US

V. Phone/Fax

Practice location:
  • Phone: 479-586-7712
  • Fax:
Mailing address:
  • Phone: 479-586-7712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP1612199
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM1706022
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: