Provider Demographics
NPI:1740925965
Name:CANADA, JAIME (PTA)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:CANADA
Suffix:
Gender:
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10601 BAKER AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:MI
Mailing Address - Zip Code:49302-9619
Mailing Address - Country:US
Mailing Address - Phone:616-401-4794
Mailing Address - Fax:
Practice Address - Street 1:44670 ANN ARBOR RD W STE 140
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-3962
Practice Address - Country:US
Practice Address - Phone:734-673-8545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA