Provider Demographics
NPI:1376946830
Name:STEPHENS, JONATHAN DAVID (PTA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:STEPHENS
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 1:1000 DES PERES RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2050
Mailing Address - Country:US
Mailing Address - Phone:314-775-0183
Mailing Address - Fax:314-775-0190
Practice Address - Street 1:1000 DES PERES RD
Practice Address - Street 2:SUITE 130
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2050
Practice Address - Country:US
Practice Address - Phone:314-775-0183
Practice Address - Fax:314-775-0190
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014024594225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant