Provider Demographics
NPI:1699872713
Name:PETERSEN, JILL A (PT)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:A
Last Name:PETERSEN
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 1:1807 SHORT BRANCH DR
Mailing Address - Street 2:#103
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4424
Mailing Address - Country:US
Mailing Address - Phone:727-372-5500
Mailing Address - Fax:727-372-8500
Practice Address - Street 1:1807 SHORT BRANCH DR
Practice Address - Street 2:103
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4424
Practice Address - Country:US
Practice Address - Phone:727-372-5500
Practice Address - Fax:727-372-8500
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21220225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106773Medicare ID - Type Unspecified