Provider Demographics
NPI:1174879951
Name:PETKUS, JILLIAN N (FNP-BC)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:N
Last Name:PETKUS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E AUBURN RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-5260
Mailing Address - Country:US
Mailing Address - Phone:248-853-2009
Mailing Address - Fax:
Practice Address - Street 1:72 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-6421
Practice Address - Country:US
Practice Address - Phone:248-236-8333
Practice Address - Fax:248-236-8666
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704266490363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1700036936Medicaid
MI1700036936Medicaid