Healthcare Provider Details

I. General information

NPI: 1558655365
Provider Name (Legal Business Name): JESSICA L DE PETRO M.S,, CGC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2011
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 MASON AVE BUILDING B, 2ND FLOOR
STATEN ISLAND NY
10305-3408
US

IV. Provider business mailing address

256 MASON AVE BUILDING B, 2ND FLOOR
STATEN ISLAND NY
10305-3408
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-6230
  • Fax: 718-226-1247
Mailing address:
  • Phone: 718-226-6230
  • Fax: 718-226-1247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: