Provider Demographics
NPI:1710283502
Name:PETRICK, JENNA
Entity Type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:
Last Name:PETRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:PETRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1070 OLD NATIONAL PIKE
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15333-2114
Mailing Address - Country:US
Mailing Address - Phone:724-632-6801
Mailing Address - Fax:724-632-6312
Practice Address - Street 1:190 BONAR AVE
Practice Address - Street 2:
Practice Address - City:WAYNESBURG
Practice Address - State:PA
Practice Address - Zip Code:15370-1604
Practice Address - Country:US
Practice Address - Phone:724-627-8156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA328834A336348OtherVALUE BEHAVIORAL HEALTH