Provider Demographics
NPI:1275578213
Name:PETROVICH, JENNIE MARIE (MSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIE
Middle Name:MARIE
Last Name:PETROVICH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5913 BAYONNE AVE
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-9501
Mailing Address - Country:US
Mailing Address - Phone:517-882-6071
Mailing Address - Fax:517-882-6383
Practice Address - Street 1:5656 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-3877
Practice Address - Country:US
Practice Address - Phone:517-882-6071
Practice Address - Fax:517-882-6383
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010619491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical