Provider Demographics
NPI:1720041759
Name:GILLIAM, JAIME M (MPT)
Entity Type:Individual
Prefix:MRS
First Name:JAIME
Middle Name:M
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MISS
Other - First Name:JAIME
Other - Middle Name:M
Other - Last Name:BAXTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:2000 RIMCREST DR
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-1174
Mailing Address - Country:US
Mailing Address - Phone:951-532-6965
Mailing Address - Fax:
Practice Address - Street 1:3179 HAMNER AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860-1983
Practice Address - Country:US
Practice Address - Phone:951-736-5646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 29672225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT296720Medicare ID - Type Unspecified