Provider Demographics
NPI:1770020422
Name:JIRON, KATIE (PT DPT)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:
Last Name:JIRON
Suffix:
Gender:F
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 VALLEJOS RD NE
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-7774
Mailing Address - Country:US
Mailing Address - Phone:505-321-5371
Mailing Address - Fax:
Practice Address - Street 1:325 S MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002
Practice Address - Country:US
Practice Address - Phone:505-321-5371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist