Provider Demographics
NPI:1689112443
Name:PETRO, JAIME (DPT)
Entity Type:Individual
Prefix:MRS
First Name:JAIME
Middle Name:
Last Name:PETRO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:LYN
Other - Last Name:EMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3305 CENTRAL PARK VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-7707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:55 HERITAGE WAY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3100
Practice Address - Country:US
Practice Address - Phone:406-471-1117
Practice Address - Fax:406-309-2076
Is Sole Proprietor?:No
Enumeration Date:2017-02-01
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT194202251P0200X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics