Provider Demographics
NPI:1629372958
Name:PETRAITIS, JENNIFER MARY (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARY
Last Name:PETRAITIS
Suffix:
Gender:F
Credentials:CRNA
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Mailing Address - Street 1:255 W MICHIGAN AVE
Mailing Address - Street 2:PO BOX 1123
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2218
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:1200 MAPLE RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-1439
Practice Address - Country:US
Practice Address - Phone:815-740-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-30
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL041.281965367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered