Basic Information
Provider Information | |||||||||
NPI: | 1649233941 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JONES | ||||||||
FirstName: | JONATHAN | ||||||||
MiddleName: | CALE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8823 PRODUCTION LN | ||||||||
Address2: |   | ||||||||
City: | OOLTEWAH | ||||||||
State: | TN | ||||||||
PostalCode: | 373636511 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4232387217 | ||||||||
FaxNumber: | 4232387217 | ||||||||
Practice Location | |||||||||
Address1: | 305 MURPHY HWY | ||||||||
Address2: | STE E | ||||||||
City: | BLAIRSVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 305123170 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7068351443 | ||||||||
FaxNumber: | 7068351437 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/08/2006 | ||||||||
LastUpdateDate: | 08/16/2016 | ||||||||
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 | PT008288 | GA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X | PT22694 | FL | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 124583015A | 05 | GA |   | MEDICAID |