Basic Information
| Provider Information | |||||||||
| NPI: | 1740815786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIXSON | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | BENNETT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4160 PARK SOUTH STATION BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282104553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365433194 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4543 CHARLOTTE HWY STE 11 | ||||||||
| Address2: | |||||||||
| City: | CLOVER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297107057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8038311454 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2020 | ||||||||
| LastUpdateDate: | 04/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 10169 | SC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | P19378 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.