Provider Demographics
NPI:1912012808
Name:LINK, JONATHAN S (MPT OCS CSCS)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:S
Last Name:LINK
Suffix:
Gender:M
Credentials:MPT OCS CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6623 LINDBLOOM LN
Mailing Address - Street 2:
Mailing Address - City:CHERRY VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61016-9137
Mailing Address - Country:US
Mailing Address - Phone:815-332-4826
Mailing Address - Fax:
Practice Address - Street 1:404 W BLACKHAWK DRIVE
Practice Address - Street 2:SUITE 1LL
Practice Address - City:BYRON
Practice Address - State:IL
Practice Address - Zip Code:61010
Practice Address - Country:US
Practice Address - Phone:815-234-5561
Practice Address - Fax:815-234-5870
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011785225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK01076Medicare ID - Type Unspecified