Provider Demographics
NPI:1376910067
Name:FETTERLY, JANETTE (PT)
Entity Type:Individual
Prefix:
First Name:JANETTE
Middle Name:
Last Name:FETTERLY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:21806 103RD AVENUE CT E
Practice Address - Street 2:STE 103
Practice Address - City:GRAHAM
Practice Address - State:WA
Practice Address - Zip Code:98338-8115
Practice Address - Country:US
Practice Address - Phone:253-847-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-28
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34641225100000X
WAPT60569869225100000X
COPTL.00013494225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist