Provider Demographics
NPI:1619598349
Name:THAMES, JONATHAN TYLER (COTA/L)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TYLER
Last Name:THAMES
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3261 MAGNOLIA BLOOM DR
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-2463
Mailing Address - Country:US
Mailing Address - Phone:601-270-7160
Mailing Address - Fax:
Practice Address - Street 1:350 GETWELL ST
Practice Address - Street 2:
Practice Address - City:MARKS
Practice Address - State:MS
Practice Address - Zip Code:38646-9785
Practice Address - Country:US
Practice Address - Phone:662-326-3690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA2418224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant