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General NPI Number Information
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NPI Number | 1245022516
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Entity Type | Individual
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Provider Name | JONATHAN CARLSON PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 05/21/2025
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Last Update Date | 05/21/2025
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Provider Practice Location Address
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Address Line | 4025 S BROADWAY AVE
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City | TYLER
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State | TX
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Zip | 75701-8727
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Country | US
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Telephone | 903-561-2690
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Fax |
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Provider Business Mailing Address
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Address Line | 7790 COUNTY ROAD 2193 APT 39
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City | WHITEHOUSE
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State | TX
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Zip | 75791-9442
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Country | US
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Telephone | 720-402-1930
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1406779
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License Number State | TX
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