Provider Demographics
NPI:1417671165
Name:PETRICK, JESSICA RAE (PNP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:RAE
Last Name:PETRICK
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 TOWNSHIP BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-1674
Mailing Address - Country:US
Mailing Address - Phone:315-487-1541
Mailing Address - Fax:315-870-3893
Practice Address - Street 1:270 TOWNSHIP BLVD
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-1674
Practice Address - Country:US
Practice Address - Phone:315-487-1541
Practice Address - Fax:315-870-3893
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY383447208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics