Provider Demographics
NPI:1124394770
Name:JACARUSO, ANTHONY
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:JACARUSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:296 JESSICAS WAY
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-3079
Mailing Address - Country:US
Mailing Address - Phone:917-853-9763
Mailing Address - Fax:
Practice Address - Street 1:406 ROY MARTIN RD STE 9
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:TN
Practice Address - Zip Code:37615-2245
Practice Address - Country:US
Practice Address - Phone:423-477-1101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018884-1225100000X
TN14601225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist