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General NPI Number Information
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NPI Number | 1972455780
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Entity Type | Individual
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Provider Name | JENNIFER DEPETRO PH.D.
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Gender | Female
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Dates
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Enumeration Date | 02/12/2026
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Last Update Date | 02/12/2026
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Provider Practice Location Address
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Address Line | 502 N CARROLL AVE STE 120
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6449
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Country | US
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Telephone | 682-292-7012
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Fax |
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Provider Business Mailing Address
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Address Line | 4421 WANDA LN
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City | FLOWER MOUND
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State | TX
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Zip | 75022-5446
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 34436
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License Number State | TX
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