Provider Demographics
NPI:1245403674
Name:JAMANTOC, MARK Z (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:Z
Last Name:JAMANTOC
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 W HORTON WAY APT 222
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-7337
Mailing Address - Country:US
Mailing Address - Phone:971-237-0772
Mailing Address - Fax:
Practice Address - Street 1:1901 HOAG RD STE B
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5626
Practice Address - Country:US
Practice Address - Phone:360-814-2184
Practice Address - Fax:360-814-5515
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4968225100000X
WAPT00010511225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0334544OtherWA L&I
OR0334543OtherWA L&I
OR0334544OtherWA L&I
OR0334544OtherWA L&I