Provider Demographics
NPI:1952320319
Name:HENRY, JONATHAN M (OTR/L)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:HENRY
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 CAMPUS DR APT 3
Mailing Address - Street 2:
Mailing Address - City:SNYDER
Mailing Address - State:NY
Mailing Address - Zip Code:14226-3704
Mailing Address - Country:US
Mailing Address - Phone:716-228-2260
Mailing Address - Fax:
Practice Address - Street 1:3495 BAILEY AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1129
Practice Address - Country:US
Practice Address - Phone:716-862-8568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011630-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist