MEDICARE: DR. JENNIFER MARIE PETRUSKA OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	27OA00609400	NJ
2	152W00000X	Optometrist	OEG001779	PA

General Provider Information

NPI Number	:	1346345121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER MARIE PETRUSKA OD

Provider Business Mailing Address
First Line	:	1950 OLD GALLOWS RD STE 520
Second Line	:
City	:	VIENNA
State	:	VA
Zip	:	22182-3970
Country	:	US
Telephone Number	:	703-847-8899
Fax Number	:	571-223-6780

Provider Business Practice Location Address
First Line	:	706 GRAPE ST
Second Line	:
City	:	WHITEHALL
State	:	PA
Zip	:	18052-5207
Country	:	US
Telephone Number	:	610-266-7700
Fax Number	:	610-266-9300

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	10/28/2020

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