Provider Demographics
NPI:1619428901
Name:SHRECKENGOST, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:SHRECKENGOST
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 1:40 BARKER ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-2404
Mailing Address - Country:US
Mailing Address - Phone:361-771-5030
Mailing Address - Fax:
Practice Address - Street 1:20 PLANTATION DR
Practice Address - Street 2:
Practice Address - City:JAFFREY
Practice Address - State:NH
Practice Address - Zip Code:03452-6631
Practice Address - Country:US
Practice Address - Phone:603-532-8762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1254225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant