Healthcare Provider Details

I. General information

NPI: 1265957989
Provider Name (Legal Business Name): JENNIFER PETRONGOLO PSYD, MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 ROUTE 33 STE 9-10
NEPTUNE NJ
07753-6102
US

IV. Provider business mailing address

2100 ROUTE 33 STE 9-10
NEPTUNE NJ
07753
US

V. Phone/Fax

Practice location:
  • Phone: 732-988-3441
  • Fax:
Mailing address:
  • Phone: 732-988-3441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35SI00626700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: