MEDICARE: JEFFREY PETREY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist

General Provider Information

NPI Number	:	1275931396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY PETREY

Provider Business Mailing Address
First Line	:	1341 ESTATES DR
Second Line	:
City	:	NEWARK
State	:	OH
Zip	:	43055-1787
Country	:	US
Telephone Number	:	740-344-6836
Fax Number	:

Provider Business Practice Location Address
First Line	:	1341 ESTATES DR
Second Line	:
City	:	NEWARK
State	:	OH
Zip	:	43055-1787
Country	:	US
Telephone Number	:	740-344-6836
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2014
Last Update Date	:	12/06/2014

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Directions to “ JEFFREY PETREY ” Practice Location

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