Healthcare Provider Details

I. General information

NPI: 1871019810
Provider Name (Legal Business Name): JESSICA SUE PETRE MSW, LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVENUE ML 6015
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

3405 COLE RD
AMELIA OH
45102-1878
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-0800
  • Fax: 513-803-0823
Mailing address:
  • Phone: 513-886-3184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1700347
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: