Provider Demographics
NPI:1083834147
Name:MAYNARD, JAMISON C (PT)
Entity Type:Individual
Prefix:
First Name:JAMISON
Middle Name:C
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5484 RICHFIELD RD.
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48506-1455
Mailing Address - Country:US
Mailing Address - Phone:810-730-6921
Mailing Address - Fax:810-515-1002
Practice Address - Street 1:5484 RICHFIELD RD.
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48506-1455
Practice Address - Country:US
Practice Address - Phone:810-730-6921
Practice Address - Fax:810-515-1002
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012257225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist