Provider Demographics
NPI:1023483922
Name:SELFRIDGE, JAMIE (MSOT, OTR/L)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:SELFRIDGE
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 RISING GLEN WAY
Mailing Address - Street 2:#208
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-2064
Mailing Address - Country:US
Mailing Address - Phone:815-546-8902
Mailing Address - Fax:
Practice Address - Street 1:2390 RISING GLEN WAY
Practice Address - Street 2:#208
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2064
Practice Address - Country:US
Practice Address - Phone:815-546-8902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15667225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist