Provider Demographics
NPI:1437775210
Name:BOOC, JARED MANLOSA
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:MANLOSA
Last Name:BOOC
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 1:421 N 20TH ST APT 102
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2848
Mailing Address - Country:US
Mailing Address - Phone:217-653-4295
Mailing Address - Fax:
Practice Address - Street 1:1440 N 10TH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-1697
Practice Address - Country:US
Practice Address - Phone:217-224-3780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056012907225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist