Provider Demographics
NPI:1134156300
Name:PETRONE, JENNIE L (LOM/DIPLOM, LAT/ATC)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:L
Last Name:PETRONE
Suffix:
Gender:F
Credentials:LOM/DIPLOM, LAT/ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 643
Mailing Address - Street 2:
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-0643
Mailing Address - Country:US
Mailing Address - Phone:570-357-1244
Mailing Address - Fax:
Practice Address - Street 1:113 N TURNPIKE RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:PA
Practice Address - Zip Code:18414-9134
Practice Address - Country:US
Practice Address - Phone:570-357-1244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2016-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001040-12255A2300X
PART0055842255A2300X
PAOM000191171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer