Basic Information
| Provider Information | |||||||||
| NPI: | 1851496020 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRINOVICH | ||||||||
| FirstName: | JODI | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1519 132ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982087203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253579380 | ||||||||
| FaxNumber: | 4253579382 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 S CEDAR ST STE B1 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984052305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532726910 | ||||||||
| FaxNumber: | 2533834218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 08/28/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00002847 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0197670 | 01 | WA | DEPT OF LABOR & INDUSTRY | OTHER | 0296929 | 01 | WA | L & I | OTHER | 8341414 | 05 | WA | MEDICAID | P00237577 | 01 | WA | RAILROAD MEDICARE | OTHER | MI8360 | 01 | WA | REGENCE BLUE SHEILD | OTHER | MI8360 | 01 | WA | PREMERA BLUE CROSS | OTHER |