Provider Demographics
NPI:1225379753
Name:NEISEN, JAMIE LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:NEISEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23505 SMITHTOWN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-4542
Mailing Address - Country:US
Mailing Address - Phone:952-470-8555
Mailing Address - Fax:
Practice Address - Street 1:23505 SMITHTOWN RD STE 100
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-4542
Practice Address - Country:US
Practice Address - Phone:952-470-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist