Provider Demographics
NPI:1073012167
Name:BURDETT, JONATHAN MARK JR
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MARK
Last Name:BURDETT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 WAUKEGAN RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-5154
Mailing Address - Country:US
Mailing Address - Phone:847-707-6744
Mailing Address - Fax:
Practice Address - Street 1:41 WAUKEGAN RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-5154
Practice Address - Country:US
Practice Address - Phone:847-707-6744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070023509225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist