Healthcare Provider Details

I. General information

NPI: 1528537958
Provider Name (Legal Business Name): JONATHAN THOMAS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 LINK DR
ROCKLEIGH NJ
07647-2504
US

IV. Provider business mailing address

52 SPRING VALLEY COMMONS
SPRING VALLEY NY
10977-4249
US

V. Phone/Fax

Practice location:
  • Phone: 201-784-1414
  • Fax:
Mailing address:
  • Phone: 845-825-7319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number40QB00349600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: