Provider Demographics
NPI:1922083781
Name:WEISS, JONATHON M (PT)
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:M
Last Name:WEISS
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 1:1630 COMMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-5753
Mailing Address - Country:US
Mailing Address - Phone:920-430-4750
Mailing Address - Fax:
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5753
Practice Address - Country:US
Practice Address - Phone:920-430-4750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4977225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4977-024OtherLICENSE
WI073050056Medicare Oscar/Certification
WI000002Medicare Oscar/Certification
WI075100114Medicare Oscar/Certification
P00697636Medicare Oscar/Certification
WI4977-024OtherLICENSE
WI100200056Medicare Oscar/Certification
WIP94831Medicare UPIN
WI000043Medicare Oscar/Certification
WI073100055Medicare Oscar/Certification