Provider Demographics
NPI:1306408885
Name:NELSON, JONATHAN RAY (LPTA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RAY
Last Name:NELSON
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 BLACK STONE CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH BELOIT
Mailing Address - State:IL
Mailing Address - Zip Code:61080-9238
Mailing Address - Country:US
Mailing Address - Phone:276-239-2368
Mailing Address - Fax:
Practice Address - Street 1:1401 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2315
Practice Address - Country:US
Practice Address - Phone:779-696-4595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160008600225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant