Provider Demographics
NPI:1043404866
Name:ERICKSON, JONATHAN (PT, MSPT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:ERICKSON
Suffix:
Gender:M
Credentials:PT, MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1051 W US ROUTE 6
Practice Address - Street 2:SUITE 400
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-4200
Practice Address - Country:US
Practice Address - Phone:815-942-8301
Practice Address - Fax:815-942-8449
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012541225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01622333OtherBLUE CROSS BLUE SHIELD ID
7454077OtherAETNA
7454077OtherAETNA