Provider Demographics
NPI:1588028682
Name:PETRENKO, JENNY (PTA)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:PETRENKO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:IEVGENIIA
Other - Middle Name:
Other - Last Name:KHODAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 WELLMORE DR
Mailing Address - Street 2:
Mailing Address - City:TEGA CAY
Mailing Address - State:SC
Mailing Address - Zip Code:29708-0124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 WELLMORE DR
Practice Address - Street 2:
Practice Address - City:TEGA CAY
Practice Address - State:SC
Practice Address - Zip Code:29708-0124
Practice Address - Country:US
Practice Address - Phone:803-836-7026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA5776225200000X
SC3526225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant