Provider Demographics
NPI:1891879094
Name:PETRIE, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PETRIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 E QUAIL RUN RD
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-5059
Mailing Address - Country:US
Mailing Address - Phone:208-365-7131
Mailing Address - Fax:208-365-4464
Practice Address - Street 1:2001 E QUAIL RUN RD
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-5059
Practice Address - Country:US
Practice Address - Phone:208-365-7131
Practice Address - Fax:208-365-4464
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7802207Q00000X
MN101703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN136314OtherUCARE
MNHP51751OtherHEALTH PARTNERS
ID8051964Medicaid
MN1043689OtherPREFERRED ONE
MN317180900Medicaid
WI34623200Medicaid
MN01-20325OtherMEDICA CHOICE
MN01-20325OtherMEDICA PRIMARY
IA0591172Medicaid
ID20008330OtherPTAN
MT2349340OtherARAZ
MN317180900Medicaid
ID11063072Medicare PIN
ID11063071Medicare PIN
ID11063071Medicare PIN