Provider Demographics
NPI:1528497260
Name:WEAVER, JAMIE (MT21003551)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:WEAVER
Suffix:
Gender:F
Credentials:MT21003551
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 MOORE ST
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-1781
Mailing Address - Country:US
Mailing Address - Phone:317-554-7656
Mailing Address - Fax:
Practice Address - Street 1:25 MOORE ST
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1781
Practice Address - Country:US
Practice Address - Phone:317-554-7656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21003551174V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174V00000XOther Service ProvidersClinical Ethicist