Provider Demographics
NPI:1376711499
Name:PETRON, JENNIFER R (MA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:PETRON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24545 104TH ST NW
Mailing Address - Street 2:
Mailing Address - City:ZIMMERMAN
Mailing Address - State:MN
Mailing Address - Zip Code:55398-8779
Mailing Address - Country:US
Mailing Address - Phone:763-856-3338
Mailing Address - Fax:
Practice Address - Street 1:112 E 5TH ST
Practice Address - Street 2:202
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-2251
Practice Address - Country:US
Practice Address - Phone:952-448-7052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1704106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist