Provider Demographics
NPI:1528575487
Name:POWELL, JONATHAN JAY SCOTT
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:JAY SCOTT
Last Name:POWELL
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 1:1801 OLIVE CHAPEL RD STE 103
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-8587
Mailing Address - Country:US
Mailing Address - Phone:919-533-8758
Mailing Address - Fax:919-535-3271
Practice Address - Street 1:2000 S GLENBURNIE RD STE 210
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5227
Practice Address - Country:US
Practice Address - Phone:252-302-5200
Practice Address - Fax:252-302-2191
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP17636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist