Provider Demographics
NPI:1487381869
Name:PETERSON, JOHNATHON DAHLIN (LCMHC, LPC)
Entity type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:DAHLIN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LCMHC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95868
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-0868
Mailing Address - Country:US
Mailing Address - Phone:801-515-5850
Mailing Address - Fax:801-254-9755
Practice Address - Street 1:1268 W SOUTH JORDAN PKWY STE 300
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4653
Practice Address - Country:US
Practice Address - Phone:801-515-5850
Practice Address - Fax:801-254-9755
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX95059101YP2500X
UT11125479-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional