Provider Demographics
NPI:1972077402
Name:THORSON, JAMIE (PTA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:THORSON
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 1:62648 710TH TRL
Mailing Address - Street 2:
Mailing Address - City:TABLE ROCK
Mailing Address - State:NE
Mailing Address - Zip Code:68447-3142
Mailing Address - Country:US
Mailing Address - Phone:402-560-4989
Mailing Address - Fax:
Practice Address - Street 1:600 I ST
Practice Address - Street 2:
Practice Address - City:PAWNEE CITY
Practice Address - State:NE
Practice Address - Zip Code:68420-3001
Practice Address - Country:US
Practice Address - Phone:402-852-2231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1754225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant