Provider Demographics
NPI:1851683221
Name:GRESS, JONATHAN EDWARD (PT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:EDWARD
Last Name:GRESS
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 1:7500 SW 30TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-1020
Mailing Address - Country:US
Mailing Address - Phone:954-452-7031
Mailing Address - Fax:954-452-7069
Practice Address - Street 1:7500 SW 30TH ST
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-1020
Practice Address - Country:US
Practice Address - Phone:954-452-7031
Practice Address - Fax:954-452-7069
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 29417225100000X
FLAL 38822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer