Provider Demographics
NPI:1508078130
Name:MULLIS, JONATHAN (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:MULLIS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13803 SWIFTWATER WAY
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-4084
Mailing Address - Country:US
Mailing Address - Phone:617-519-6443
Mailing Address - Fax:
Practice Address - Street 1:701 MANATEE AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-8604
Practice Address - Country:US
Practice Address - Phone:617-519-6443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15359225100000X
FLPT32979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist