Provider Demographics
NPI:1558655365
Name:DE PETRO, JESSICA L (MS,, CGC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:DE PETRO
Suffix:
Gender:F
Credentials:MS,, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 MASON AVE
Mailing Address - Street 2:BUILDING B, 2ND FLOOR
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3408
Mailing Address - Country:US
Mailing Address - Phone:718-226-6230
Mailing Address - Fax:718-226-1247
Practice Address - Street 1:256 MASON AVE
Practice Address - Street 2:BUILDING B, 2ND FLOOR
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3408
Practice Address - Country:US
Practice Address - Phone:718-226-6230
Practice Address - Fax:718-226-1247
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS