Provider Demographics
NPI:1851496020
Name:PETRINOVICH, JODI J (PT)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:J
Last Name:PETRINOVICH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 132ND ST SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-7203
Mailing Address - Country:US
Mailing Address - Phone:425-357-9380
Mailing Address - Fax:425-357-9382
Practice Address - Street 1:1901 S CEDAR ST STE B1
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2305
Practice Address - Country:US
Practice Address - Phone:253-272-6910
Practice Address - Fax:253-383-4218
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002847225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0197670OtherDEPT OF LABOR & INDUSTRY
WA0296929OtherL & I
WA8341414Medicaid
WAP00237577OtherRAILROAD MEDICARE
WAMI8360OtherREGENCE BLUE SHEILD
WAMI8360OtherPREMERA BLUE CROSS
WAG8909776Medicare PIN
WAMI8360OtherREGENCE BLUE SHEILD