Basic Information
| Provider Information | |||||||||
| NPI: | 1366960684 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STARKE | ||||||||
| FirstName: | JONATHON | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 BERRYWOOD DR STE 204 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734496082 | ||||||||
| FaxNumber: | 5734490401 | ||||||||
| Practice Location | |||||||||
| Address1: | 3301 BERRYWOOD DR STE 204 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652016517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734496082 | ||||||||
| FaxNumber: | 5734490401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2017027012 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2017027012 | 01 | MO | MISSOURI BOARD OF HEALING ARTS | OTHER |