=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497966238
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA ANN PETERSON LICSW, CSW-PIP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 01/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1585 THOMAS CENTER DR STE 104
-----------------------------------------------------
City | EAGAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55122-3039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-560-0900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6485 134TH ST W
-----------------------------------------------------
City | APPLE VALLEY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55124-7917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-303-1856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 4550
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 3028
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 20365
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------