Provider Demographics
NPI:1558645572
Name:BOUTNI, JONATHAN (PT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BOUTNI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 32008
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507
Mailing Address - Country:US
Mailing Address - Phone:810-230-0338
Mailing Address - Fax:810-715-5005
Practice Address - Street 1:10293 DIXIE HIGHWAY
Practice Address - Street 2:SUITE 0
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442
Practice Address - Country:US
Practice Address - Phone:810-771-7686
Practice Address - Fax:810-771-7685
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015725225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist