Provider Demographics
NPI:1508218835
Name:PETRELLI, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PETRELLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:HETTENBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:223 EDWARDS AVE
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08007-1233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 E GATE DR
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-2803
Practice Address - Country:US
Practice Address - Phone:856-810-7599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-16-22463103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ203617435OtherPROVIDERTAX ID NUMBER