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NPI Code Detail

MEDICARE: JENNIFER PETERSON

MEDICARE: JENNIFER PETERSON
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
11041C0700XClinical Social Worker15305MN

General Provider Information

NPI Number : 1780004127
Entity Type Code : Individual
Provider Name (Legal Business Name) : JENNIFER PETERSON
Provider Business Mailing Address
First Line : 8640 EAGLE CREEK CIR
Second Line :
City : SAVAGE
State : MN
Zip : 55378-4400
Country : US
Telephone Number : 952-746-7664
Fax Number : 952-746-0582
Provider Business Practice Location Address
First Line : 8640 EAGLE CREEK CIR
Second Line :
City : SAVAGE
State : MN
Zip : 55378-4400
Country : US
Telephone Number : 952-746-7664
Fax Number : 952-746-0582
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/24/2014
Last Update Date : 04/24/2014

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