Provider Demographics
NPI:1437423035
Name:JEROME, KATRINA (PTA)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:JEROME
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 OVERHILL RD
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-5643
Mailing Address - Country:US
Mailing Address - Phone:860-749-5352
Mailing Address - Fax:
Practice Address - Street 1:1 OVERHILL RD
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-5643
Practice Address - Country:US
Practice Address - Phone:860-749-5352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001131225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001131OtherSTATE LICENSE