Provider Demographics
NPI:1285125575
Name:PETROLE, JONATHAN THOMAS (MS, LPC)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:THOMAS
Last Name:PETROLE
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 NORTH CHESTNUT STREET
Mailing Address - Street 2:
Mailing Address - City:TRESCKOW
Mailing Address - State:PA
Mailing Address - Zip Code:18254
Mailing Address - Country:US
Mailing Address - Phone:570-582-8621
Mailing Address - Fax:
Practice Address - Street 1:36 NORTH CHESTNUT STREET
Practice Address - Street 2:
Practice Address - City:TRESCKOW
Practice Address - State:PA
Practice Address - Zip Code:18254
Practice Address - Country:US
Practice Address - Phone:570-582-8621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005442270002Medicaid