Provider Demographics
NPI:1013009539
Name:PETRY, JILL K (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:K
Last Name:PETRY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2024 ARCHWAY DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-2661
Mailing Address - Country:US
Mailing Address - Phone:636-346-7501
Mailing Address - Fax:
Practice Address - Street 1:100 E VINE ST
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-3734
Practice Address - Country:US
Practice Address - Phone:888-508-6778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005017813225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant