MEDICARE: JONATHAN PE PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251X0800X	Orthopedic Physical Therapist	26125	CA

General Provider Information

NPI Number	:	1710351747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN PE PT

Provider Business Mailing Address
First Line	:	18109 SMOKESIGNAL DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92127-3108
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18109 SMOKESIGNAL DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92127-3108
Country	:	US
Telephone Number	:	858-442-5843
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2015
Last Update Date	:	11/13/2015

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