Provider Demographics
NPI:1083142178
Name:GILL, JONATHAN MICHAEL (DPT, CSCS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:GILL
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 CHELTON CT SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3827 JIMMY LEE SMITH PKWY # 22
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2804
Practice Address - Country:US
Practice Address - Phone:770-943-1142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012867225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist