Provider Demographics
NPI:1275262966
Name:WEAKLEY, JAIMIE (MT)
Entity Type:Individual
Prefix:
First Name:JAIMIE
Middle Name:
Last Name:WEAKLEY
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3118
Mailing Address - Country:US
Mailing Address - Phone:719-251-8824
Mailing Address - Fax:
Practice Address - Street 1:108 W 5TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3118
Practice Address - Country:US
Practice Address - Phone:719-251-8824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0018058225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist