Provider Demographics
NPI:1205068301
Name:JAYNE, BRANDON MICHAEL (MSPT)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:MICHAEL
Last Name:JAYNE
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 S MEMORIAL HWY
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:TRUCKSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18708-1418
Mailing Address - Country:US
Mailing Address - Phone:570-575-6064
Mailing Address - Fax:
Practice Address - Street 1:165 S MEMORIAL HWY
Practice Address - Street 2:SUITE 2C
Practice Address - City:TRUCKSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18708-1418
Practice Address - Country:US
Practice Address - Phone:570-575-6064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-23
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0002506225100000X
PAPT020216225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist