Provider Demographics
NPI:1073947107
Name:BRYANT, JONAH M (PTA)
Entity Type:Individual
Prefix:
First Name:JONAH
Middle Name:M
Last Name:BRYANT
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 1:8017 PRESTON POINTE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-5700
Mailing Address - Country:US
Mailing Address - Phone:214-864-5059
Mailing Address - Fax:
Practice Address - Street 1:600 TRAIL RIDGE RD
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:IN
Practice Address - Zip Code:46701-1541
Practice Address - Country:US
Practice Address - Phone:260-636-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004658A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant