Provider Demographics
NPI:1356325203
Name:WOLFF, JONATHAN D (MSPT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:WOLFF
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 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:
Practice Address - Street 1:112 2ND ST NW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677
Practice Address - Country:US
Practice Address - Phone:319-352-0102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008088225100000X
COPTL8014225100000X
IA090538225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8438939Medicaid
WAG8868656Medicare PIN