Provider Demographics
NPI:1164602587
Name:PETRYCZKIEWYCZ, JILL M (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:M
Last Name:PETRYCZKIEWYCZ
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 N 107TH ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53225-4524
Mailing Address - Country:US
Mailing Address - Phone:414-217-4438
Mailing Address - Fax:
Practice Address - Street 1:13000 W BLUEMOUND RD
Practice Address - Street 2:SUITE 300
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2650
Practice Address - Country:US
Practice Address - Phone:414-217-4438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2506-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist