Provider Demographics
NPI:1861144768
Name:PETERSON, JIMMIE RAY
Entity type:Individual
Prefix:
First Name:JIMMIE
Middle Name:RAY
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2085 JADE LN
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2862
Mailing Address - Country:US
Mailing Address - Phone:612-619-1047
Mailing Address - Fax:
Practice Address - Street 1:2085 JADE LN
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2862
Practice Address - Country:US
Practice Address - Phone:612-619-1047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker