Provider Demographics
NPI:1821227935
Name:PETKOS, JENNIFER R (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:R
Last Name:PETKOS
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 E PASSAIC AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3832
Mailing Address - Country:US
Mailing Address - Phone:646-259-1681
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:212-746-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF335842-1363LF0000X
NY335842363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner