Healthcare Provider Details

I. General information

NPI: 1831735141
Provider Name (Legal Business Name): JON WALTER PETERSEN MA, M.ED, LPCC, CMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 FORD RD STE B
ST LOUIS PARK MN
55426-1115
US

IV. Provider business mailing address

4240 PARK GLEN RD
ST LOUIS PARK MN
55416-5427
US

V. Phone/Fax

Practice location:
  • Phone: 952-378-1800
  • Fax: 952-378-1714
Mailing address:
  • Phone: 612-925-6033
  • Fax: 612-925-8496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12348521-6004
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2463
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: