Provider Demographics
NPI:1528593985
Name:JON PETRUSCHKE LLC
Entity Type:Organization
Organization Name:JON PETRUSCHKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRUSCHKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-774-9667
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 ST
Practice Address - Street 2:SUITE 2
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4261
Practice Address - Country:US
Practice Address - Phone:207-774-9667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty