Basic Information
| Provider Information | |||||||||
| NPI: | 1790295012 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORRISON | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | RAY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4118 RED ARROW RD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485075406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045313769 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4500 S SAGINAW ST | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485072676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8108936489 | ||||||||
| FaxNumber: | 8102130283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2017 | ||||||||
| LastUpdateDate: | 10/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | M993623 | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 465278468 | 05 | MI | MEDICAID | 4652848 | 01 | MI | COMMERCIAAL | OTHER |