Provider Demographics
NPI:1902201601
Name:GARDNER, JAIME RENEE (PTA)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:RENEE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 ROSEMONT DR
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-2639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 W CRAWFORD ST
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-1903
Practice Address - Country:US
Practice Address - Phone:418-238-1761
Practice Address - Fax:418-238-5055
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08646225200000X
IN06004856A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant