Healthcare Provider Details

I. General information

NPI: 1104737261
Provider Name (Legal Business Name): MR. JOHN NATHAN JAMISON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19931 W KELLOGG DR UNIT A
GODDARD KS
67052-8864
US

IV. Provider business mailing address

1138 W SHELLBARK ST
GODDARD KS
67052-2702
US

V. Phone/Fax

Practice location:
  • Phone: 316-550-6132
  • Fax:
Mailing address:
  • Phone: 316-323-0041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14-04454
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: