Healthcare Provider Details

I. General information

NPI: 1972367829
Provider Name (Legal Business Name): JONATHAN PUTNAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2024
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4847 KAYLEE AVE STE B
SPRINGDALE AR
72762-0872
US

IV. Provider business mailing address

3435 W CLEARWOOD DR
FAYETTEVILLE AR
72704-6127
US

V. Phone/Fax

Practice location:
  • Phone: 479-756-5002
  • Fax:
Mailing address:
  • Phone: 479-200-0309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4386
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: