Provider Demographics
NPI:1699006833
Name:AYCOCK, JON RYAN (PT)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:RYAN
Last Name:AYCOCK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 COFFEE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1315
Mailing Address - Country:US
Mailing Address - Phone:209-549-4626
Mailing Address - Fax:209-549-4625
Practice Address - Street 1:3500 COFFEE RD STE 3
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1315
Practice Address - Country:US
Practice Address - Phone:209-549-4626
Practice Address - Fax:209-549-4625
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36312225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist