Provider Demographics
NPI:1376242610
Name:JARAMILLO, BRIAN KEITH (CMT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:JARAMILLO
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 WILL SCARLET LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4618
Mailing Address - Country:US
Mailing Address - Phone:707-486-2354
Mailing Address - Fax:
Practice Address - Street 1:1825 WILL SCARLET LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4618
Practice Address - Country:US
Practice Address - Phone:707-486-2354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86518225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist