Provider Demographics
NPI:1407092604
Name:DAVIS, JAMIE LYNNE (DAOM, LAC)
Entity Type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:LYNNE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DAOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30736 HIGHWAY 200 STE 104
Mailing Address - Street 2:
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-8701
Mailing Address - Country:US
Mailing Address - Phone:208-264-0644
Mailing Address - Fax:
Practice Address - Street 1:30736 HIGHWAY 200 STE 104
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-8701
Practice Address - Country:US
Practice Address - Phone:208-264-0644
Practice Address - Fax:888-979-6134
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-18
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC600065362171100000X
WAMA00023205225700000X
IDACU-348171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDACU-348OtherINSURANCE