Provider Demographics
NPI:1629654561
Name:LANDERS, JAMIE NICOLE (MOT)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:NICOLE
Last Name:LANDERS
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:NICOLE
Other - Last Name:LATHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:2222 POSHARD DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-1843
Practice Address - Country:US
Practice Address - Phone:855-324-0885
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31007354A225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN448223OtherNBCOT CERTIFICATION
IN31007354AOtherOCCUPATIONAL THERAPY LICENSE