Provider Demographics
NPI:1538646799
Name:LANGLEY, JONATHAN MICHAEL
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:LANGLEY
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 1:113 E CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-8244
Mailing Address - Country:US
Mailing Address - Phone:574-727-4242
Mailing Address - Fax:
Practice Address - Street 1:1220 LAGUNA ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-2330
Practice Address - Country:US
Practice Address - Phone:765-457-8273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005734A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant