Provider Demographics
NPI:1114136082
Name:JARAMILLO, JULIE ROSE (PTA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ROSE
Last Name:JARAMILLO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 N FRONTIER ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-5529
Mailing Address - Country:US
Mailing Address - Phone:505-634-3619
Mailing Address - Fax:505-634-3675
Practice Address - Street 1:325 N BERGIN LN
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-6729
Practice Address - Country:US
Practice Address - Phone:505-632-4333
Practice Address - Fax:505-634-3675
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA291225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64434826Medicaid