Provider Demographics
NPI:1124526934
Name:PETROPOULOS, JACQUELYN P (PTA)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:P
Last Name:PETROPOULOS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1409
Mailing Address - Country:US
Mailing Address - Phone:414-443-1269
Mailing Address - Fax:414-443-1285
Practice Address - Street 1:2500 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-1409
Practice Address - Country:US
Practice Address - Phone:414-443-1269
Practice Address - Fax:414-443-1285
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI221225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant