Healthcare Provider Details

I. General information

NPI: 1174641476
Provider Name (Legal Business Name): JACK S PETRAS LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 05/24/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1595 LAKEVIEW AVE
DRACUT MA
01826-3396
US

IV. Provider business mailing address

1595 LAKEVIEW AVE
DRACUT MA
01826-3396
US

V. Phone/Fax

Practice location:
  • Phone: 978-455-2628
  • Fax: 978-746-9480
Mailing address:
  • Phone: 978-455-2628
  • Fax: 978-746-9480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number863
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: