Provider Demographics
NPI:1780028472
Name:SULLIVAN, JAIME (LMT)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:2405 SE 17TH ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-9192
Mailing Address - Country:US
Mailing Address - Phone:952-280-0095
Mailing Address - Fax:
Practice Address - Street 1:2405 SE 17TH ST
Practice Address - Street 2:SUITE 401
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-9192
Practice Address - Country:US
Practice Address - Phone:352-280-0095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA63388172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist