Provider Demographics
NPI:1548520125
Name:PETTUS, JAMIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:
Last Name:PETTUS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:GAY
Other - Last Name:PETTUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6601 BLALOCK FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRING
Mailing Address - State:NC
Mailing Address - Zip Code:27592-8977
Mailing Address - Country:US
Mailing Address - Phone:540-447-0091
Mailing Address - Fax:
Practice Address - Street 1:6601 BLALOCK FOREST DR
Practice Address - Street 2:
Practice Address - City:WILLOW SPRING
Practice Address - State:NC
Practice Address - Zip Code:27592-8977
Practice Address - Country:US
Practice Address - Phone:540-447-0091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-17
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2709103T00000X
VA0810005815103TC0700X
NC6537103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist