Provider Demographics
NPI:1063553360
Name:JARAMILLO, TARA K (SLP)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:K
Last Name:JARAMILLO
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 642
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-0642
Mailing Address - Country:US
Mailing Address - Phone:505-838-0800
Mailing Address - Fax:505-838-3999
Practice Address - Street 1:1115 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-0642
Practice Address - Country:US
Practice Address - Phone:505-838-0800
Practice Address - Fax:505-838-3999
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1487235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM88722520OtherMEDICAID PCO
NMD4005Medicaid
NM00P3051OtherMEDICAID-ASC