Provider Demographics
NPI:1619416542
Name:LANE, JAYME (PTA)
Entity Type:Individual
Prefix:
First Name:JAYME
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 N JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-8760
Mailing Address - Country:US
Mailing Address - Phone:812-890-6593
Mailing Address - Fax:
Practice Address - Street 1:200 W 4TH ST
Practice Address - Street 2:
Practice Address - City:OAKTOWN
Practice Address - State:IN
Practice Address - Zip Code:47561-8081
Practice Address - Country:US
Practice Address - Phone:812-745-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-12
Last Update Date:2017-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003909A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant