Provider Demographics
NPI:1750842423
Name:PEARSON, JONATHAN ERIC (PTA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ERIC
Last Name:PEARSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PLATTEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53818-2826
Mailing Address - Country:US
Mailing Address - Phone:951-795-2271
Mailing Address - Fax:
Practice Address - Street 1:91 ARIES LN
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3309
Practice Address - Country:US
Practice Address - Phone:541-963-8678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORCP000178A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty