Provider Demographics
NPI:1770874588
Name:EWING, JAMIE CAROL (LMT,PTA)
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:CAROL
Last Name:EWING
Suffix:
Gender:F
Credentials:LMT,PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 DUGWAY CT
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-5535
Mailing Address - Country:US
Mailing Address - Phone:304-640-2980
Mailing Address - Fax:
Practice Address - Street 1:1304 DUGWAY CT
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-5535
Practice Address - Country:US
Practice Address - Phone:304-640-2980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001522225200000X
WV2001-1648225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant