Provider Demographics
NPI:1083763502
Name:PETRICK, JON S (DC)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:S
Last Name:PETRICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 N PECOS RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7319
Mailing Address - Country:US
Mailing Address - Phone:702-948-2520
Mailing Address - Fax:702-948-2523
Practice Address - Street 1:58 N PECOS RD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7319
Practice Address - Country:US
Practice Address - Phone:702-948-2520
Practice Address - Fax:702-948-2523
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB00848111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV36349Medicare PIN
NV489916Medicare UPIN
NVU89916Medicare UPIN