Provider Demographics
NPI:1508126434
Name:ELENBAAS, JON GARRETT (PTA)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:GARRETT
Last Name:ELENBAAS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1695
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49422-1695
Mailing Address - Country:US
Mailing Address - Phone:616-392-3197
Mailing Address - Fax:616-392-7959
Practice Address - Street 1:3491 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MI
Practice Address - Zip Code:49419-9512
Practice Address - Country:US
Practice Address - Phone:269-751-2150
Practice Address - Fax:269-751-2140
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003533225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant