Provider Demographics
NPI:1114148616
Name:PETTIJOHN, JEANNE CAROL (LSCSW)
Entity Type:Individual
Prefix:MRS
First Name:JEANNE
Middle Name:CAROL
Last Name:PETTIJOHN
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:CAROL
Other - Last Name:STALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:8101 OVERLAND PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66204
Mailing Address - Country:US
Mailing Address - Phone:913-385-3020
Mailing Address - Fax:913-888-8454
Practice Address - Street 1:8101 OVERLAND PARK DRIVE
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66204
Practice Address - Country:US
Practice Address - Phone:913-385-3020
Practice Address - Fax:913-888-8454
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical