Provider Demographics
NPI:1770712358
Name:PETRONELLA, JENNIFER LYNN (DPM)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:PETRONELLA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9640 COMMERCE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-4167
Mailing Address - Country:US
Mailing Address - Phone:248-360-3888
Mailing Address - Fax:
Practice Address - Street 1:9640 COMMERCE RD
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-4166
Practice Address - Country:US
Practice Address - Phone:248-360-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-05
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002333213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N78970 004Medicare PIN