=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912319955
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW MICHAEL JONES PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2014
-----------------------------------------------------
Last Update Date | 05/26/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1051 CLARK ST
-----------------------------------------------------
City | REEDSBURG
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53959-2321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-524-7500
-----------------------------------------------------
Fax | 608-524-7599
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 SHARON ST PO BOX 60
-----------------------------------------------------
City | ARENA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53503-9612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-216-1396
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2160-19
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------