Provider Demographics
NPI:1033466768
Name:PETRIK, JEFFREY M (PT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:PETRIK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25229 S SUN LAKES BLVD
Mailing Address - Street 2:119
Mailing Address - City:SUN LAKES
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-6453
Mailing Address - Country:US
Mailing Address - Phone:480-883-6734
Mailing Address - Fax:480-895-8143
Practice Address - Street 1:25229 S SUN LAKES BLVD
Practice Address - Street 2:119
Practice Address - City:SUN LAKES
Practice Address - State:AZ
Practice Address - Zip Code:85248-6453
Practice Address - Country:US
Practice Address - Phone:480-883-6734
Practice Address - Fax:480-895-8143
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1491225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist