Provider Demographics
NPI:1104848225
Name:TIPTON, JONATHAN JAY (PT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:JAY
Last Name:TIPTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8400 E FLORENTINE RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-8653
Mailing Address - Country:US
Mailing Address - Phone:928-775-9999
Mailing Address - Fax:928-775-9998
Practice Address - Street 1:8400 E FLORENTINE RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-8653
Practice Address - Country:US
Practice Address - Phone:928-775-9999
Practice Address - Fax:928-775-9998
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5049225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ766305Medicaid
AZP00212103Medicare Oscar/Certification
AZ766305Medicaid
AZ670847OtherUNITED HEALTHCARE ID#
AZ766305Medicaid
AZ3Z2680OtherHEALTHNET ID
AZZ72692Medicare ID - Type UnspecifiedGROUP #
AZDD1708Medicare ID - Type UnspecifiedRR MEDICARE GROUP #