Provider Demographics
NPI:1952701856
Name:WISE-PETRENKO, JENNIFER (LMFT, LPCC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WISE-PETRENKO
Suffix:
Gender:F
Credentials:LMFT, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11512 B AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-2605
Mailing Address - Country:US
Mailing Address - Phone:530-889-7607
Mailing Address - Fax:
Practice Address - Street 1:11512 B AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2605
Practice Address - Country:US
Practice Address - Phone:530-889-7974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6782101YP2500X
CA110441106H00000X
CALMFT110441106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional