Provider Demographics
NPI:1003299744
Name:MATTSWELL, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:MATTSWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:MARKWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:512 E COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:CORRY
Mailing Address - State:PA
Mailing Address - Zip Code:16407-9014
Mailing Address - Country:US
Mailing Address - Phone:814-664-9346
Mailing Address - Fax:814-663-0169
Practice Address - Street 1:512 E COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:CORRY
Practice Address - State:PA
Practice Address - Zip Code:16407-9014
Practice Address - Country:US
Practice Address - Phone:814-664-9346
Practice Address - Fax:814-663-0169
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT024398225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032477930003Medicaid