Provider Demographics
NPI:1760053086
Name:PETROVIC, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:PETROVIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 NE DIVISION ST STE 201
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3572
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 NE DIVISION ST STE 201
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3572
Practice Address - Country:US
Practice Address - Phone:541-516-6330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)