Provider Demographics
NPI:1730275678
Name:PETTIFORD, JEANETTE (MA)
Entity type:Individual
Prefix:MS
First Name:JEANETTE
Middle Name:
Last Name:PETTIFORD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7638 WINDBRIDGE DR APT 119
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-4961
Mailing Address - Country:US
Mailing Address - Phone:916-417-5350
Mailing Address - Fax:
Practice Address - Street 1:2130 STOCKTON BLVD BLDG 100
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1337
Practice Address - Country:US
Practice Address - Phone:916-875-0701
Practice Address - Fax:916-854-8814
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106149106H00000X
103TC1900X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9582Medicare ID - Type Unspecified