Healthcare Provider Details

I. General information

NPI: 1487739603
Provider Name (Legal Business Name): JEFFREY ROBERT PETRA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 COOPER POINT RD SW STE 17
OLYMPIA WA
98502-1179
US

IV. Provider business mailing address

PO BOX 11009
OLYMPIA WA
98508-1009
US

V. Phone/Fax

Practice location:
  • Phone: 360-754-4662
  • Fax: 360-352-3289
Mailing address:
  • Phone: 360-352-2037
  • Fax: 360-352-0637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: