Provider Demographics
NPI:1760666820
Name:PRUETT, JAIME L (PTA)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:L
Last Name:PRUETT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2536 W INDUSTRIAL PARK DR
Mailing Address - Street 2:STE 11
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-2635
Mailing Address - Country:US
Mailing Address - Phone:812-332-7529
Mailing Address - Fax:812-339-7529
Practice Address - Street 1:2536 W INDUSTRIAL PARK DR
Practice Address - Street 2:STE 11
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-2635
Practice Address - Country:US
Practice Address - Phone:812-332-7529
Practice Address - Fax:812-339-7529
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN06001047A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant