Provider Demographics
NPI:1942411392
Name:ROSE, JONATHAN MICHAEL
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:ROSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JON
Other - Middle Name:M
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT,
Mailing Address - Street 1:824 COUNTRY CLUB LN
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-4241
Mailing Address - Country:US
Mailing Address - Phone:901-734-1228
Mailing Address - Fax:
Practice Address - Street 1:930 MADISON AVE
Practice Address - Street 2:SUITE 660
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-0001
Practice Address - Country:US
Practice Address - Phone:901-448-2057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT 80682251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic