Provider Demographics
NPI:1902357114
Name:PETRUCELLI, JESSICA (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PETRUCELLI
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:VA
Mailing Address - Zip Code:24551-2653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:VA
Practice Address - Zip Code:24551-2653
Practice Address - Country:US
Practice Address - Phone:434-386-8982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000873103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst