Provider Demographics
NPI:1033493622
Name:EVANS, JONATHAN (DPT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11170 RILLITO LN
Mailing Address - Street 2:301
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-2079
Mailing Address - Country:US
Mailing Address - Phone:260-570-8239
Mailing Address - Fax:
Practice Address - Street 1:12722 TONKEL RD STE 102
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-8201
Practice Address - Country:US
Practice Address - Phone:260-739-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-01
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0104532251X0800X
IN05011654A2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201289270Medicaid