| NPI | 1770567935 |
|---|---|
| Former Name | JETTA PETRIE |
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: WY 466) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: CO 152633) |
| 1041C0700X Social Worker, Clinical (Licence: MA 111787) | |
| Enumeration Date | 2005-12-01 |
| Last Update Date | 2007-07-08 |