Provider Demographics
NPI:1689844144
Name:JARDINE, TAMARA K (PT)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:K
Last Name:JARDINE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:K
Other - Last Name:WEAKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3740 EDISON LAKES PKWY
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3474
Mailing Address - Country:US
Mailing Address - Phone:574-252-4150
Mailing Address - Fax:574-252-4159
Practice Address - Street 1:24 N SAINT JOSEPH AVE
Practice Address - Street 2:SUITE 'B'
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2263
Practice Address - Country:US
Practice Address - Phone:269-684-6870
Practice Address - Fax:269-684-9573
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIKD070312OtherBCBS
IN000000093083OtherBCBS
IN000000093083OtherBCBS