Basic Information
| Provider Information | |||||||||
| NPI: | 1922623388 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERMANSEN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2965 E TARPON DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082879420 | ||||||||
| FaxNumber: | 2082879426 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 E. CLINIC WAY | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PAROWAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4354770095 | ||||||||
| FaxNumber: | 4352460352 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2020 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11775831-2401 | UT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.