Basic Information
| Provider Information | |||||||||
| NPI: | 1629654561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDERS | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MOT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LATHAM | ||||||||
| OtherFirstName: | JAMIE | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BLVD STE 3070 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | 3175208200 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 POSHARD DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472031843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | 3175208200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2021 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | 31007354A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 448223 | 01 | IN | NBCOT CERTIFICATION | OTHER | 31007354A | 01 | IN | OCCUPATIONAL THERAPY LICENSE | OTHER |