Provider Demographics
NPI:1720394174
Name:LARSEN, JAMIE LYNN (DPT)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:LARSEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2713
Mailing Address - Country:US
Mailing Address - Phone:208-746-0455
Mailing Address - Fax:208-746-0688
Practice Address - Street 1:1010 BRYDEN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2713
Practice Address - Country:US
Practice Address - Phone:208-746-0455
Practice Address - Fax:208-746-0688
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2265225100000X
WA00010795225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist