MEDICARE: DR. JONATHAN BENNETT HIXSON DPT

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	225100000X	Physical Therapist	10169	SC
2	225100000X	Physical Therapist	P19378	NC

General Provider Information

NPI Number	:	1740815786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN BENNETT HIXSON DPT

Provider Business Mailing Address
First Line	:	4160 PARK SOUTH STATION BLVD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28210-4553
Country	:	US
Telephone Number	:	336-543-3194
Fax Number	:

Provider Business Practice Location Address
First Line	:	4543 CHARLOTTE HWY STE 11
Second Line	:
City	:	CLOVER
State	:	SC
Zip	:	29710-7057
Country	:	US
Telephone Number	:	803-831-1454
Fax Number	:

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

Provider Enumeration Date	:	03/10/2020
Last Update Date	:	04/27/2020

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