Active NPI
Jacqueline Bernadine Petravage, M.D.
- Psychiatry Physician
- Salt Lake City, UT
National Provider Identifier
1104861079
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychiatry Physician
- License
- 1664161205
- Practice address
- Veteran'S Hospital, 500 Foothill Blvd
BLDG 47
Salt Lake City, UT 84148-0001 - Phone
- (801) 582-1565
- Fax
- (801) 584-2544
- NPI assigned
- Jun 17, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychiatry Physician | 2084P0800X | 1664161205 | UT | Primary |
Addresses
Primary practice location
Veteran'S Hospital, 500 Foothill Blvd
BLDG 47
Salt Lake City, UT 84148-0001
Mailing address
500 Foothill Blvd
Salt Lake City, UT 84148-0001
Phone (801) 582-1565
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1664161205 | UT | MD | Psychiatry Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1150502400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1783900800000",
"number": "1104861079",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "500 FOOTHILL BLVD",
"city": "SALT LAKE CITY",
"state": "UT",
"postal_code": "841480001",
"telephone_number": "801-582-1565",
"fax_number": "801-584-2544"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "VETERAN'S HOSPITAL, 500 FOOTHILL BLVD",
"address_2": "BLDG 47",
"city": "SALT LAKE CITY",
"state": "UT",
"postal_code": "841480001",
"telephone_number": "801-582-1565",
"fax_number": "801-584-2544"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETRAVAGE",
"first_name": "JACQUELINE",
"middle_name": "BERNADINE",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-06-17",
"last_updated": "2026-07-13",
"status": "A"
},
"taxonomies": [
{
"code": "2084P0800X",
"taxonomy_group": "",
"desc": "Psychiatry & Neurology, Psychiatry",
"state": "UT",
"license": "1664161205",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Salt Lake City, UT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 13, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.