Basic Information
Provider Information | |||||||||
NPI: | 1366796112 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EBERSOLE | ||||||||
FirstName: | JONATHAN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 771 PILOT HOUSE DR | ||||||||
Address2: | SUITE A | ||||||||
City: | NEWPORT NEWS | ||||||||
State: | VA | ||||||||
PostalCode: | 236061990 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7578732302 | ||||||||
FaxNumber: | 7578732306 | ||||||||
Practice Location | |||||||||
Address1: | 4831 S LABURNUM AVE | ||||||||
Address2: |   | ||||||||
City: | RICHMOND | ||||||||
State: | VA | ||||||||
PostalCode: | 232312713 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8042220745 | ||||||||
FaxNumber: | 8042220748 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2012 | ||||||||
LastUpdateDate: | 03/13/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305207689 | VA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | C05954 | 01 | VA | GROUP MEDICARE PTAN | OTHER | Q41989A | 01 | VA | MEDICARE PTAN | OTHER | 1366796112 | 01 | VA | MEDICAID QMB | OTHER |