Provider Demographics
NPI:1619377751
Name:PROVOST, JONATHAN MICHAEL (PT, DPT, SCS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:PROVOST
Suffix:
Gender:M
Credentials:PT, DPT, SCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01035-9558
Mailing Address - Country:US
Mailing Address - Phone:413-586-5552
Mailing Address - Fax:
Practice Address - Street 1:241 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01035-9558
Practice Address - Country:US
Practice Address - Phone:413-586-5552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21309225100000X
CT010287225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist