Provider Demographics
NPI:1437635497
Name:BURRUP, JONATHAN (PT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BURRUP
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 1:7201 W CLEARWATER AVE STE B101
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1694
Mailing Address - Country:US
Mailing Address - Phone:509-544-0265
Mailing Address - Fax:509-987-1614
Practice Address - Street 1:35 S LOUISIANA ST STE A140
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-8632
Practice Address - Country:US
Practice Address - Phone:509-582-0429
Practice Address - Fax:509-582-1182
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62874225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR62874OtherOREGON PHYSICAL THERAPY LICENSE