Provider Demographics
NPI:1174259642
Name:BERNHARDT, JONATHAN ROBERT (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROBERT
Last Name:BERNHARDT
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8059 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-1839
Mailing Address - Country:US
Mailing Address - Phone:262-995-4158
Mailing Address - Fax:
Practice Address - Street 1:7300 WASHINGTON AVE STE B
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-6525
Practice Address - Country:US
Practice Address - Phone:262-321-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10623225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist