Healthcare Provider Details

I. General information

NPI: 1104302298
Provider Name (Legal Business Name): JONATHON WESLEY GARDNER PT, DPT, SCS, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 PROVIDENCE RD STE 100
CHARLOTTE NC
28207-1251
US

IV. Provider business mailing address

131 PROVIDENCE RD STE 100
CHARLOTTE NC
28207-1251
US

V. Phone/Fax

Practice location:
  • Phone: 980-265-8869
  • Fax:
Mailing address:
  • Phone: 980-265-8869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number11288
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number27017
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberP23364
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: