Provider Demographics
NPI:1740859123
Name:JUPITER, PETRINA (PSYD)
Entity type:Individual
Prefix:DR
First Name:PETRINA
Middle Name:
Last Name:JUPITER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:PROF
Other - First Name:PETRINA
Other - Middle Name:
Other - Last Name:JUPITER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CHRISTIAN COUNSELOR
Mailing Address - Street 1:11940 BRICKSOME AVE STE C
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-2594
Mailing Address - Country:US
Mailing Address - Phone:225-250-5829
Mailing Address - Fax:
Practice Address - Street 1:11940 BRICKSOME AVE STE C
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-2594
Practice Address - Country:US
Practice Address - Phone:225-250-5829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator