Provider Demographics
NPI:1922623388
Name:HERMANSEN, JONATHAN JAMES (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:JAMES
Last Name:HERMANSEN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2965 E TARPON DR STE 150
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9007
Mailing Address - Country:US
Mailing Address - Phone:208-287-9420
Mailing Address - Fax:208-287-9426
Practice Address - Street 1:450 E. CLINIC WAY
Practice Address - Street 2:SUITE B
Practice Address - City:PAROWAN
Practice Address - State:UT
Practice Address - Zip Code:84761
Practice Address - Country:US
Practice Address - Phone:435-477-0095
Practice Address - Fax:435-246-0352
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11775831-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist