Provider Demographics
NPI:1043517840
Name:ROBERSON, JONATHAN BENJAMIN (DPT)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BENJAMIN
Last Name:ROBERSON
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 1:317 E WACKERLY ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-7062
Mailing Address - Country:US
Mailing Address - Phone:989-631-4100
Mailing Address - Fax:989-631-1154
Practice Address - Street 1:317 E WACKERLY ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-7062
Practice Address - Country:US
Practice Address - Phone:989-631-4100
Practice Address - Fax:989-631-1154
Is Sole Proprietor?:No
Enumeration Date:2011-02-15
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist