Provider Demographics
NPI:1639408602
Name:WIEKAMP, JAMIE T (DPT 36269)
Entity type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:T
Last Name:WIEKAMP
Suffix:
Gender:F
Credentials:DPT 36269
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 W WILSHIRE AVE
Mailing Address - Street 2:STE C
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1858
Mailing Address - Country:US
Mailing Address - Phone:530-518-8673
Mailing Address - Fax:
Practice Address - Street 1:141 W WILSHIRE AVE
Practice Address - Street 2:STE C
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1858
Practice Address - Country:US
Practice Address - Phone:530-518-8673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-21
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 36269174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT36269OtherPHYSICAL THERAPY LICENSE