Provider Demographics
NPI:1225037864
Name:GREEN, JAIME RACINE (MSPT)
Entity Type:Individual
Prefix:MS
First Name:JAIME
Middle Name:RACINE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 CARP RIVER LN STE 2
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849-3187
Mailing Address - Country:US
Mailing Address - Phone:906-401-0196
Mailing Address - Fax:906-401-0276
Practice Address - Street 1:350 IRON ST
Practice Address - Street 2:
Practice Address - City:NEGAUNEE
Practice Address - State:MI
Practice Address - Zip Code:49866-1830
Practice Address - Country:US
Practice Address - Phone:906-401-0196
Practice Address - Fax:906-401-0276
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011232225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR133796Medicare ID - Type Unspecified