Provider Demographics
NPI:1629642343
Name:CARMONA, JERECK
Entity Type:Individual
Prefix:
First Name:JERECK
Middle Name:
Last Name:CARMONA
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 1:9083 WYATT CT SE
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501
Mailing Address - Country:US
Mailing Address - Phone:253-820-6521
Mailing Address - Fax:
Practice Address - Street 1:4520 INTELCO LOOP SE STE 4E
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-6012
Practice Address - Country:US
Practice Address - Phone:360-402-6776
Practice Address - Fax:360-347-1850
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61161777225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist