Provider Demographics
NPI:1467136903
Name:PEREZ, JITKA
Entity Type:Individual
Prefix:
First Name:JITKA
Middle Name:
Last Name:PEREZ
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 1:1218 LEFTHAND DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6514
Mailing Address - Country:US
Mailing Address - Phone:720-341-6732
Mailing Address - Fax:
Practice Address - Street 1:600 S AIRPORT RD
Practice Address - Street 2:BUILDING B, SUITE C
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503
Practice Address - Country:US
Practice Address - Phone:720-491-3402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0015351208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation