Provider Demographics
NPI:1154714756
Name:CARLSON, JAMIE LEIGH
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:LEIGH
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16985 W BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5909
Mailing Address - Country:US
Mailing Address - Phone:262-821-4460
Mailing Address - Fax:
Practice Address - Street 1:16985 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5909
Practice Address - Country:US
Practice Address - Phone:262-821-4460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-06
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14663225100000X
WI16482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer