Provider Demographics
NPI:1225658123
Name:MENDICELLI, JONATHAN M (PTA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:MENDICELLI
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18256 SWISS DR APT 16
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9741
Mailing Address - Country:US
Mailing Address - Phone:231-878-7161
Mailing Address - Fax:
Practice Address - Street 1:280 W 40TH ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4664
Practice Address - Country:US
Practice Address - Phone:616-796-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502006160225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant