Provider Demographics
NPI:1275966194
Name:WARDLAW, JAIMIE LEIGH (OTA/L)
Entity Type:Individual
Prefix:MRS
First Name:JAIMIE
Middle Name:LEIGH
Last Name:WARDLAW
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:OKEENE
Mailing Address - State:OK
Mailing Address - Zip Code:73763-9369
Mailing Address - Country:US
Mailing Address - Phone:580-822-1585
Mailing Address - Fax:
Practice Address - Street 1:7617 NW 133RD PL
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-4451
Practice Address - Country:US
Practice Address - Phone:405-206-1242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1233224ZE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantEnvironmental Modification