Provider Demographics
NPI:1821564873
Name:RANEY, JONATHAN BLAKE (PTA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BLAKE
Last Name:RANEY
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 1:205 BRADLEY ROAD 42 W
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71647-9279
Mailing Address - Country:US
Mailing Address - Phone:870-820-6209
Mailing Address - Fax:
Practice Address - Street 1:778 SCOGIN DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5729
Practice Address - Country:US
Practice Address - Phone:870-460-3540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4359225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant