Provider Demographics
NPI:1285144279
Name:PETRONE, JESSICA SUSAN (LPC)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:SUSAN
Last Name:PETRONE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 BONNYWOOD LN APT 202
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-5217
Mailing Address - Country:US
Mailing Address - Phone:301-903-3875
Mailing Address - Fax:
Practice Address - Street 1:7134 GRAND PRAIRIE DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-8763
Practice Address - Country:US
Practice Address - Phone:970-633-0925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0014067101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional