Provider Demographics
NPI:1538675210
Name:BOONE, JONATHAN KEITH
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:KEITH
Last Name:BOONE
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 1:2741 OCEAN CLUB BLVD APT 107
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33019-3935
Mailing Address - Country:US
Mailing Address - Phone:302-222-8726
Mailing Address - Fax:
Practice Address - Street 1:7500 SW 30TH ST
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-1020
Practice Address - Country:US
Practice Address - Phone:954-452-7012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2020-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT341372251S0007X, 225100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program