Provider Demographics
NPI:1699116434
Name:ROSS, JAIMIE KAHAULANI (DPT, LMT)
Entity type:Individual
Prefix:MISS
First Name:JAIMIE
Middle Name:KAHAULANI
Last Name:ROSS
Suffix:
Gender:F
Credentials:DPT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 ERIE BLVD W
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2904
Mailing Address - Country:US
Mailing Address - Phone:315-292-8744
Mailing Address - Fax:
Practice Address - Street 1:900 ERIE BLVD W
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2904
Practice Address - Country:US
Practice Address - Phone:315-292-8744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022822225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist