Provider Demographics
NPI:1619373321
Name:MCKINLEY, JAIME
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:MCKINLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 MAIN ST
Mailing Address - Street 2:STE 308
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-1559
Mailing Address - Country:US
Mailing Address - Phone:765-644-0500
Mailing Address - Fax:765-644-0510
Practice Address - Street 1:800 MAIN ST
Practice Address - Street 2:STE 308
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-1559
Practice Address - Country:US
Practice Address - Phone:765-644-0500
Practice Address - Fax:765-644-0510
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002395A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant