Healthcare Provider Details

I. General information

NPI: 1649584004
Provider Name (Legal Business Name): JONATHAN ROBERT VANCE D.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 N CENTENNIAL WAY STE 150
MESA AZ
85201-6689
US

IV. Provider business mailing address

123 N CENTENNIAL WAY STE 150
MESA AZ
85201-6689
US

V. Phone/Fax

Practice location:
  • Phone: 480-687-8051
  • Fax: 480-546-3731
Mailing address:
  • Phone: 480-687-8051
  • Fax: 480-546-3731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9010
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberLPT-00009010
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberLPT-00009010
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: