Provider Demographics
NPI:1306021910
Name:PETRUSCHKE, JON P (LCSW)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:P
Last Name:PETRUSCHKE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3208
Mailing Address - Country:US
Mailing Address - Phone:207-774-9667
Mailing Address - Fax:
Practice Address - Street 1:145 NEWBURY STREET
Practice Address - Street 2:STE 2
Practice Address - City:PORTLAND
Practice Address - State:MAINE
Practice Address - Zip Code:04101
Practice Address - Country:UM
Practice Address - Phone:207-774-9667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC88351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical