Provider Demographics
NPI:1255842134
Name:PETRETEE, JACKLYN ROSE
Entity Type:Individual
Prefix:
First Name:JACKLYN
Middle Name:ROSE
Last Name:PETRETEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24850 E STONECREST AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-3403
Mailing Address - Country:US
Mailing Address - Phone:509-230-4630
Mailing Address - Fax:
Practice Address - Street 1:24850 E STONECREST AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-3403
Practice Address - Country:US
Practice Address - Phone:509-230-4630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist