Provider Demographics
NPI:1710468400
Name:APPLEGATE, JAIME RAE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:RAE
Last Name:APPLEGATE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:RAE
Other - Last Name:STACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2310 CALIFORNIA RD STE A
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1228
Mailing Address - Country:US
Mailing Address - Phone:574-264-0791
Mailing Address - Fax:574-262-5183
Practice Address - Street 1:1400 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4488
Practice Address - Country:US
Practice Address - Phone:574-971-1815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05013090A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300020482Medicaid