Healthcare Provider Details

I. General information

NPI: 1003547977
Provider Name (Legal Business Name): JONATHAN DAVID PETERS MA, LPCC, LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2022
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 N DEARBORN ST
CHICAGO IL
60610-3310
US

IV. Provider business mailing address

5534 N KENMORE AVE APT 309
CHICAGO IL
60640-1544
US

V. Phone/Fax

Practice location:
  • Phone: 800-257-7800
  • Fax: 312-943-3530
Mailing address:
  • Phone: 612-810-8128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number304604
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC03364
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: