Provider Demographics
NPI:1821326620
Name:NOWAK, JAIME L (MPT)
Entity Type:Individual
Prefix:MRS
First Name:JAIME
Middle Name:L
Last Name:NOWAK
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:L
Other - Last Name:KENNY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:4800 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-1176
Mailing Address - Country:US
Mailing Address - Phone:248-673-0500
Mailing Address - Fax:248-673-6077
Practice Address - Street 1:4800 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-1176
Practice Address - Country:US
Practice Address - Phone:248-673-0500
Practice Address - Fax:248-673-6077
Is Sole Proprietor?:No
Enumeration Date:2009-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011226225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM78530005Medicare PIN