Healthcare Provider Details

I. General information

NPI: 1902351554
Provider Name (Legal Business Name): JAMIE LYNN HAYNES PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 HOMEWOOD BLVD
GLASGOW KY
42141-3468
US

IV. Provider business mailing address

198 S FORK TERRACE RD
GLASGOW KY
42141-9638
US

V. Phone/Fax

Practice location:
  • Phone: 270-651-6126
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA03497
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number49591
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code225CX0006X
TaxonomyOrientation and Mobility Training Rehabilitation Counselor
License NumberCP017255A
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: