Provider Demographics
NPI:1033361894
Name:PETRY, JILL (PT)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:PETRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 OLD MONTICELLO ROAD
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:NY
Mailing Address - Zip Code:12734
Mailing Address - Country:US
Mailing Address - Phone:845-292-1624
Mailing Address - Fax:845-292-1650
Practice Address - Street 1:30 HATFIELD LN
Practice Address - Street 2:SUITE 201
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-6766
Practice Address - Country:US
Practice Address - Phone:845-294-0779
Practice Address - Fax:845-294-9497
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028008225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist