Provider Demographics
NPI:1417180266
Name:PATRICK, JONATHAN (PT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:PATRICK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 DAVIS RD W
Mailing Address - Street 2:
Mailing Address - City:OLD LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06371-1448
Mailing Address - Country:US
Mailing Address - Phone:860-434-9155
Mailing Address - Fax:
Practice Address - Street 1:6 DAVIS RD W
Practice Address - Street 2:
Practice Address - City:OLD LYME
Practice Address - State:CT
Practice Address - Zip Code:06371-1448
Practice Address - Country:US
Practice Address - Phone:860-434-9155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist