Provider Demographics
NPI:1033815949
Name:CARLOS, JONATHAN REX (PTA)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN REX
Middle Name:
Last Name:CARLOS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10670 SLATER AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4806
Mailing Address - Country:US
Mailing Address - Phone:714-586-2498
Mailing Address - Fax:
Practice Address - Street 1:10670 SLATER AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4806
Practice Address - Country:US
Practice Address - Phone:714-586-2498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2173815225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2173815OtherTEXAS BOARD OF PHYSICAL THERAPY
TX2173815OtherTEXAS BOARD OF PHYICAL THERAPY