Provider Demographics
NPI:1659476570
Name:PETERY, JAN L (PT)
Entity Type:Individual
Prefix:MR
First Name:JAN
Middle Name:L
Last Name:PETERY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 CHRISTINA CIR
Mailing Address - Street 2:
Mailing Address - City:SCHWENKSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19473-2340
Mailing Address - Country:US
Mailing Address - Phone:610-287-1581
Mailing Address - Fax:
Practice Address - Street 1:1524 DEKALB PIKE
Practice Address - Street 2:
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-3348
Practice Address - Country:US
Practice Address - Phone:610-275-0330
Practice Address - Fax:610-275-2455
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT0007947L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA035372NV7Medicare ID - Type Unspecified