Healthcare Provider Details

I. General information

NPI: 1487381869
Provider Name (Legal Business Name): JOHNATHON DAHLIN PETERSON LCMHC, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 09/25/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1268 W SOUTH JORDAN PKWY STE 300
SOUTH JORDAN UT
84095-4653
US

IV. Provider business mailing address

PO BOX 95868
SOUTH JORDAN UT
84095-0868
US

V. Phone/Fax

Practice location:
  • Phone: 801-515-5850
  • Fax: 801-254-9755
Mailing address:
  • Phone: 801-515-5850
  • Fax: 801-254-9755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11125479-6004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number95059
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: