Provider Demographics
NPI:1285426502
Name:BANNON, JAMIE LYN (DPT)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYN
Last Name:BANNON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 LUCIA DR
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-8330
Mailing Address - Country:US
Mailing Address - Phone:413-281-7848
Mailing Address - Fax:
Practice Address - Street 1:361 NEWBURY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-2727
Practice Address - Country:US
Practice Address - Phone:617-302-6244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA165342251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics