Provider Demographics
NPI:1205403391
Name:NORMAN, JONATHAN (DPT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:NORMAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5850 N FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-5466
Mailing Address - Country:US
Mailing Address - Phone:082-960-7274
Mailing Address - Fax:
Practice Address - Street 1:5850 N FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-5466
Practice Address - Country:US
Practice Address - Phone:208-960-7274
Practice Address - Fax:208-318-1080
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-7402225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist