Provider Demographics
NPI:1962733014
Name:PETRO, JENNIFER (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:PETRO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1360 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-1006
Mailing Address - Country:US
Mailing Address - Phone:585-465-3174
Mailing Address - Fax:
Practice Address - Street 1:1360 MONROE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-1006
Practice Address - Country:US
Practice Address - Phone:585-465-3174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016738103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical