Provider Demographics
NPI:1831635580
Name:JARAMILLO, MARK
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:JARAMILLO
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 1:50 ANDRES SANCHEZ RD
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-8193
Mailing Address - Country:US
Mailing Address - Phone:505-859-2057
Mailing Address - Fax:
Practice Address - Street 1:1115 N CALIFORNIA ST STE B
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-4265
Practice Address - Country:US
Practice Address - Phone:575-838-7632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1703225X00000X
NM3652225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist