MEDICARE: JENNIFER PETERSEN LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	17473	MN

General Provider Information

NPI Number	:	1588318737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER PETERSEN LICSW

Provider Business Mailing Address
First Line	:	6528 NEWTON AVE S
Second Line	:
City	:	RICHFIELD
State	:	MN
Zip	:	55423-1116
Country	:	US
Telephone Number	:	612-710-7770
Fax Number	:

Provider Business Practice Location Address
First Line	:	4748 CHICAGO AVE STE 4
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-4320
Country	:	US
Telephone Number	:	612-710-7770
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2022
Last Update Date	:	02/07/2022

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