Provider Demographics
NPI:1629113873
Name:EVANS, JAMIE LYNN (DPT)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:EVANS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LYNN
Other - Last Name:SCHROEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:11470 BUSINESS BLVD
Mailing Address - Street 2:#200
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577
Mailing Address - Country:US
Mailing Address - Phone:907-696-5678
Mailing Address - Fax:907-696-5678
Practice Address - Street 1:11470 BUSINESS BLVD
Practice Address - Street 2:#200
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577
Practice Address - Country:US
Practice Address - Phone:907-696-5678
Practice Address - Fax:907-696-5678
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1674225100000X
MN7460225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT65871Medicaid
AK160602Medicare ID - Type Unspecified