Provider Demographics
NPI:1780883199
Name:NIEVES, JAIME LUIS JR (PTA)
Entity type:Individual
Prefix:MR
First Name:JAIME
Middle Name:LUIS
Last Name:NIEVES
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123B HOLLYWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-5629
Mailing Address - Country:US
Mailing Address - Phone:908-531-9224
Mailing Address - Fax:
Practice Address - Street 1:32 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:KEANSBURG
Practice Address - State:NJ
Practice Address - Zip Code:07734-1125
Practice Address - Country:US
Practice Address - Phone:732-787-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40 QB00191000225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant