Provider Demographics
NPI:1730970443
Name:PETYKOWSKI, JONATHAN RUSSELL
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RUSSELL
Last Name:PETYKOWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 FRONT ST STE 108
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-1805
Mailing Address - Country:US
Mailing Address - Phone:720-310-0530
Mailing Address - Fax:
Practice Address - Street 1:700 FRONT ST STE 108
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-1805
Practice Address - Country:US
Practice Address - Phone:720-310-0530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-13
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099317871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical