Provider Demographics
NPI:1154174712
Name:PETRUSKA, JENNIFER REBECCA (NNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:REBECCA
Last Name:PETRUSKA
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6819 PINERIDGE CT
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-5557
Mailing Address - Country:US
Mailing Address - Phone:330-207-5002
Mailing Address - Fax:
Practice Address - Street 1:8401 MARKET ST
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6725
Practice Address - Country:US
Practice Address - Phone:330-729-4250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-11
Last Update Date:2024-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.390544163WN0002X
OHAPRN.CNP.0037112363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care