Provider Demographics
NPI:1598052417
Name:BASS, JONATHAN GARRETT (DPT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:GARRETT
Last Name:BASS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 W GALLATIN ST
Mailing Address - Street 2:P.O. BOX 508
Mailing Address - City:HAZLEHURST
Mailing Address - State:MS
Mailing Address - Zip Code:39083-3007
Mailing Address - Country:US
Mailing Address - Phone:601-894-5929
Mailing Address - Fax:601-894-2693
Practice Address - Street 1:126 W GALLATIN ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:MS
Practice Address - Zip Code:39083-3007
Practice Address - Country:US
Practice Address - Phone:601-894-5929
Practice Address - Fax:601-894-2693
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4913225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist