Provider Demographics
NPI:1013682426
Name:JARUKAMON, JARUPONG (PTA)
Entity Type:Individual
Prefix:
First Name:JARUPONG
Middle Name:
Last Name:JARUKAMON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 E OLIVE RD APT 12A
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-4571
Mailing Address - Country:US
Mailing Address - Phone:850-217-1848
Mailing Address - Fax:
Practice Address - Street 1:288 E OLIVE RD APT 12A
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-4571
Practice Address - Country:US
Practice Address - Phone:850-217-1848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30718225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant