Provider Demographics
NPI:1043576036
Name:NICK, JAMIE LYNN (PT)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:NICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LYNN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4950 W 23RD ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-5802
Mailing Address - Country:US
Mailing Address - Phone:814-459-2755
Mailing Address - Fax:814-456-4873
Practice Address - Street 1:4950 W 23RD ST
Practice Address - Street 2:SUITE 1
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-5802
Practice Address - Country:US
Practice Address - Phone:814-459-2755
Practice Address - Fax:814-456-4873
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT020926225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist