Provider Demographics
NPI:1518574789
Name:YOUNGBLOOD, JONATHAN TODD
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TODD
Last Name:YOUNGBLOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9301 N CENTRAL EXPY
Mailing Address - Street 2:STE 500
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-0805
Mailing Address - Country:US
Mailing Address - Phone:806-683-0711
Mailing Address - Fax:
Practice Address - Street 1:9301 N CENTRAL EXPY STE 500
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0805
Practice Address - Country:US
Practice Address - Phone:214-220-2468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
TX13092362081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty