Healthcare Provider Details

I. General information

NPI: 1659216919
Provider Name (Legal Business Name): JENNIFER ANN PETERSON LSUDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 E 800 N
OREM UT
84097-4314
US

IV. Provider business mailing address

1080 E 800 N
OREM UT
84097-4314
US

V. Phone/Fax

Practice location:
  • Phone: 801-420-0089
  • Fax:
Mailing address:
  • Phone: 801-420-0089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14272543-6006
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: