Provider Demographics
NPI:1417312588
Name:SAMUELSON, JONATHAN LEE (PT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LEE
Last Name:SAMUELSON
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 1:5213 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4430
Mailing Address - Country:US
Mailing Address - Phone:919-620-4917
Mailing Address - Fax:
Practice Address - Street 1:162 LEGACY OAKS DR
Practice Address - Street 2:SUITE 2102
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-6556
Practice Address - Country:US
Practice Address - Phone:919-373-1799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16003225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist