Provider Demographics
NPI:1659764298
Name:GILLIS, JONATHAN R (DPT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:R
Last Name:GILLIS
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 1:80 TECHNACENTER DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-6028
Mailing Address - Country:US
Mailing Address - Phone:334-625-5795
Mailing Address - Fax:334-396-4905
Practice Address - Street 1:4900 IVEY RD NW STE 1001
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4106
Practice Address - Country:US
Practice Address - Phone:770-917-0924
Practice Address - Fax:770-917-0926
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011834225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA13681075OtherCAQH
GA13681075OtherCAQH