Basic Information
| Provider Information | |||||||||
| NPI: | 1164548608 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUM | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | D.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31309 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900310309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238651200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1640 MARENGO ST | ||||||||
| Address2: | #102 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900331036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238651200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 09/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | PT32686 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 2251S0007X | PT32686 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 225100000X | PT32686 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.