Provider Demographics
NPI:1114688090
Name:SO, JONATHAN (DC)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:SO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 TUDOR CITY PL APT 1825
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-6877
Mailing Address - Country:US
Mailing Address - Phone:732-858-4000
Mailing Address - Fax:
Practice Address - Street 1:721 N BEERS ST STE 1E
Practice Address - Street 2:
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1500
Practice Address - Country:US
Practice Address - Phone:732-858-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-04
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00790900111N00000X
NY013552111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor