Provider Demographics
NPI:1144784349
Name:SEELEY, JAMIE LYN (PTA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYN
Last Name:SEELEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LYN
Other - Last Name:CARPENTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:616 MELROSE DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3251
Mailing Address - Country:US
Mailing Address - Phone:208-589-1879
Mailing Address - Fax:
Practice Address - Street 1:3111 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7534
Practice Address - Country:US
Practice Address - Phone:208-529-0067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-5114225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant