Provider Demographics
NPI:1821219585
Name:PEITZ, JENNA DANIELLE
Entity Type:Individual
Prefix:MISS
First Name:JENNA
Middle Name:DANIELLE
Last Name:PEITZ
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 1:2939 W. ALEXIS ROAD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43613-2059
Mailing Address - Country:US
Mailing Address - Phone:419-474-7279
Mailing Address - Fax:
Practice Address - Street 1:27064 OAKMEAD DRIVE
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-2657
Practice Address - Country:US
Practice Address - Phone:419-874-6957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT10373225100000X
MI5501011483225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2308185Medicaid
OH341952632-00OtherWORKERS COMP
OH341952632-00OtherWORKERS COMP