Provider Demographics
NPI:1295381093
Name:PETRICH, JEREMY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:PETRICH
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 BOOTH ST APT 11
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66103-2847
Mailing Address - Country:US
Mailing Address - Phone:417-861-3860
Mailing Address - Fax:
Practice Address - Street 1:2020 N COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1614
Practice Address - Country:US
Practice Address - Phone:417-861-3860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist