Provider Demographics
NPI:1184869703
Name:ROSALES, JEROME ALEGADO (PT)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:ALEGADO
Last Name:ROSALES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7614 COVINGTON HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6153
Mailing Address - Country:US
Mailing Address - Phone:260-432-8344
Mailing Address - Fax:
Practice Address - Street 1:7614 COVINGTON HOLLOW LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6153
Practice Address - Country:US
Practice Address - Phone:260-432-8344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05005566A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist