Provider Demographics
NPI:1902351554
Name:HAYNES, JAMIE LYNN (PTA)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:HAYNES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 S FORK TERRACE RD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-9638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 HOMEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3468
Practice Address - Country:US
Practice Address - Phone:270-651-6126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-23
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTCP017255A225CX0006X
KYA03497225200000X
CA49591225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225CX0006XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorOrientation and Mobility Training Provider
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant