Provider Demographics
NPI:1861017907
Name:HEALY, JAMIE (LMT)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:HEALY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S24W37908 HIDDEN PASS
Mailing Address - Street 2:
Mailing Address - City:DOUSMAN
Mailing Address - State:WI
Mailing Address - Zip Code:53118-9430
Mailing Address - Country:US
Mailing Address - Phone:262-443-7718
Mailing Address - Fax:
Practice Address - Street 1:1300 N SUMMIT AVE STE 201
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4467
Practice Address - Country:US
Practice Address - Phone:262-443-7718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11219-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist