Provider Demographics
NPI:1487717625
Name:STALEY, JAMIE JILL (MSPT)
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:JILL
Last Name:STALEY
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1987 W PINE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48615
Mailing Address - Country:US
Mailing Address - Phone:989-842-3460
Mailing Address - Fax:989-842-5688
Practice Address - Street 1:1987 W PINE RIVER RD
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MI
Practice Address - Zip Code:48615
Practice Address - Country:US
Practice Address - Phone:989-842-3460
Practice Address - Fax:989-842-5688
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010668225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist