Provider Demographics
NPI:1407328917
Name:HOLMAN, JAMIE M (LPTA, CST)
Entity Type:Individual
Prefix:MR
First Name:JAMIE
Middle Name:M
Last Name:HOLMAN
Suffix:
Gender:M
Credentials:LPTA, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 TOBIN DR APT 101
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-1358
Mailing Address - Country:US
Mailing Address - Phone:260-414-4440
Mailing Address - Fax:
Practice Address - Street 1:21450 ARCHWOOD CIR
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-4127
Practice Address - Country:US
Practice Address - Phone:260-415-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN5502002609225200000X
MI5502002609225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
11231982OtherMEDICARE
IN11231982Medicaid
MI11231982Medicaid