Healthcare Provider Details

I. General information

NPI: 1154714756
Provider Name (Legal Business Name): MRS. JAMIE LEIGH CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2015
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16985 W BLUEMOUND RD
BROOKFIELD WI
53005-5909
US

IV. Provider business mailing address

16985 W BLUEMOUND RD
BROOKFIELD WI
53005-5909
US

V. Phone/Fax

Practice location:
  • Phone: 262-821-4460
  • Fax:
Mailing address:
  • Phone: 262-821-4460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14663
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1648
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: