Provider Demographics
NPI:1972244002
Name:CARLSON, JAMIE (PT,DPT)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:BOTSCHNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:65 E WADSWORTH PARK DR STE 230
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8096
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1841 LANE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-3007
Practice Address - Country:US
Practice Address - Phone:937-609-7362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH013366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1891391934OtherSWORD HEALTH