Provider Demographics
NPI:1487661690
Name:MAYNE, JONATHAN A (MPT)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:A
Last Name:MAYNE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2432
Mailing Address - Country:US
Mailing Address - Phone:770-479-5535
Mailing Address - Fax:770-479-8821
Practice Address - Street 1:320 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2432
Practice Address - Country:US
Practice Address - Phone:770-479-5535
Practice Address - Fax:770-479-8821
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT005996225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
65BBDNMMedicare ID - Type Unspecified