Provider Demographics
NPI:1588769418
Name:PETERY, JACQUELINE A (PT)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:A
Last Name:PETERY
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 1:214 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
PAPT007318L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA035374NV7Medicare ID - Type Unspecified