Provider Demographics
NPI:1215282744
Name:PETTI, JEANNINE MARIE (LSW, LCDCIII)
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:MARIE
Last Name:PETTI
Suffix:
Gender:F
Credentials:LSW, LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9083 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6462
Mailing Address - Country:US
Mailing Address - Phone:440-255-0678
Mailing Address - Fax:440-255-6348
Practice Address - Street 1:9083 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6462
Practice Address - Country:US
Practice Address - Phone:440-255-0678
Practice Address - Fax:440-255-6348
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH121142101YA0400X
OH0600839104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker