Provider Demographics
NPI:1225790215
Name:KOTH, JONATHAN EDWARD (LAT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:EDWARD
Last Name:KOTH
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-2109
Mailing Address - Country:US
Mailing Address - Phone:715-898-1600
Mailing Address - Fax:
Practice Address - Street 1:204 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-2109
Practice Address - Country:US
Practice Address - Phone:715-898-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2431-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer