Provider Demographics
NPI:1982058749
Name:JIMERSON, MICHELLE ANN (DPT)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:ANN
Last Name:JIMERSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:987 R C HOAG DR
Mailing Address - Street 2:
Mailing Address - City:SALAMANCA
Mailing Address - State:NY
Mailing Address - Zip Code:14779-1365
Mailing Address - Country:US
Mailing Address - Phone:716-945-5894
Mailing Address - Fax:716-242-6345
Practice Address - Street 1:275 THOMAS INDIAN SCHOOL DR
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:NY
Practice Address - Zip Code:14081-9341
Practice Address - Country:US
Practice Address - Phone:716-532-5582
Practice Address - Fax:716-242-6344
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039312225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06899334Medicaid