Jon Walter Petersen, MA, M.ED, LPCC, CMHC

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

2463 Issued in MN

Practice address

1155 Ford Rd Ste B
St Louis Park, MN 55426-1115

Phone

(952) 378-1800

Fax

(952) 378-1714

NPI assigned

Nov 21, 2019

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Mental Health Counselor

Education

Other, 2012

Medicare assignment

May accept Medicare assignment

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Master of Education, Master of Arts

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Medicine Lake Consultation Group,PLLC

  • Psychiatry Physician
  • St Louis Park, MN
  • NPI 1881753564
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1574294400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1749772800000",
    "number": "1831735141",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4240 PARK GLEN RD",
            "city": "ST LOUIS PARK",
            "state": "MN",
            "postal_code": "554165427",
            "telephone_number": "612-925-6033",
            "fax_number": "612-925-8496"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1155 FORD RD STE B",
            "city": "ST LOUIS PARK",
            "state": "MN",
            "postal_code": "554261115",
            "telephone_number": "952-378-1800",
            "fax_number": "952-378-1714"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "JON",
        "middle_name": "WALTER",
        "credential": "MA, M.ED, LPCC, CMHC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-11-21",
        "last_updated": "2025-06-13",
        "certification_date": "2025-06-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "UT",
            "license": "12348521-6004",
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": "MN",
            "license": "2463",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Joy Marie Petermann, MSW LICSW
• Amanda Leigh Peters, PT
• Samantha Macy Peters
• Ann S Petersen, PHARMD.
• Carol Ann Petersen, LICSW
• Lydia Petersen, LGSW, LADC
• Bradley J Peterson, MD
• Carrie M Peterson
• Eleanor Joie Peterson
• Emily Peterson

• Professional Counselor in St Louis Park, MN
• Providers in St Louis Park, MN by specialty
• Professional Counselor in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 13, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.