Provider Demographics
NPI:1538921259
Name:PETRAUSKAS, JACKSON ALEXANDER
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:ALEXANDER
Last Name:PETRAUSKAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4837 ROCKY MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80109-8690
Mailing Address - Country:US
Mailing Address - Phone:172-030-0227
Mailing Address - Fax:
Practice Address - Street 1:4837 ROCKY MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80109-8690
Practice Address - Country:US
Practice Address - Phone:720-300-2271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program