Provider Demographics
NPI:1316581564
Name:PETERSON, JANIS KAITLIN (DPT)
Entity Type:Individual
Prefix:
First Name:JANIS
Middle Name:KAITLIN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5629
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47716-5629
Mailing Address - Country:US
Mailing Address - Phone:812-759-7476
Mailing Address - Fax:812-401-3259
Practice Address - Street 1:6005 TIMBER RIDGE DR
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-8134
Practice Address - Country:US
Practice Address - Phone:502-292-0800
Practice Address - Fax:502-292-0400
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007850225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist