Provider Demographics
NPI:1427137702
Name:PUNO, JACQUELINE LIANA (PT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LIANA
Last Name:PUNO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:LIANA
Other - Last Name:NAVARRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:6397 LEE HWY STE 300
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2564
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:13035 KANSAS AVE
Practice Address - Street 2:
Practice Address - City:BONNER SPRINGS
Practice Address - State:KS
Practice Address - Zip Code:66012
Practice Address - Country:US
Practice Address - Phone:913-721-6362
Practice Address - Fax:913-422-6675
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004012265225100000X
KS11-03429225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
37606031OtherBCBS KC
MOMA4370065OtherMEDICARE PTAN
KSKA2868008OtherMEDICARE PTAN
750842OtherOPTUM
KSP01246857OtherMEDICARE RAILROAD