Provider Demographics
NPI:1275599979
Name:RENNER, JONATHAN PAUL (MSPT)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:PAUL
Last Name:RENNER
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 VINEWOOD
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192
Mailing Address - Country:US
Mailing Address - Phone:734-752-5006
Mailing Address - Fax:
Practice Address - Street 1:1701SOUTH BLD EAST
Practice Address - Street 2:#110
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307
Practice Address - Country:US
Practice Address - Phone:248-853-4431
Practice Address - Fax:248-853-5048
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012445225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist