Healthcare Provider Details

I. General information

NPI: 1679981567
Provider Name (Legal Business Name): JESSICA PETRILAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2014
Last Update Date: 07/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2741 BOULEVARD AVE
SCRANTON PA
18509-1000
US

IV. Provider business mailing address

2741 BOULEVARD AVE
SCRANTON PA
18509-1000
US

V. Phone/Fax

Practice location:
  • Phone: 570-344-6121
  • Fax:
Mailing address:
  • Phone: 570-344-6121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOP005915
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: