Healthcare Provider Details

I. General information

NPI: 1841703691
Provider Name (Legal Business Name): JONATHAN DAVID HARDY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 MILSTEAD RD NE
CONYERS GA
30012-3824
US

IV. Provider business mailing address

2100 W IRIS DR SE APT B1104
CONYERS GA
30013-1912
US

V. Phone/Fax

Practice location:
  • Phone: 470-545-0860
  • Fax:
Mailing address:
  • Phone: 256-496-4955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTH10496
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT016761
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: