Healthcare Provider Details

I. General information

NPI: 1447175682
Provider Name (Legal Business Name): JEREMY PETERSON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 W MORENO AVE
COLORADO SPRINGS CO
80905-1731
US

IV. Provider business mailing address

875 W MORENO AVE
COLORADO SPRINGS CO
80905-1731
US

V. Phone/Fax

Practice location:
  • Phone: 719-572-6100
  • Fax:
Mailing address:
  • Phone: 719-572-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0024393
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: