Provider Demographics
NPI:1720366263
Name:COLLINSWORTH, JONATHAN EVAN (CMT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:EVAN
Last Name:COLLINSWORTH
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7060 COLUMBIA PIKE
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-3104
Mailing Address - Country:US
Mailing Address - Phone:703-916-8782
Mailing Address - Fax:
Practice Address - Street 1:7060 COLUMBIA PIKE
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-3104
Practice Address - Country:US
Practice Address - Phone:703-916-8782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019009890225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist