Provider Demographics
NPI:1962371963
Name:ANDERSON, JON RICHARD (PTA)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:RICHARD
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6998 OLD CUSSETA RD
Mailing Address - Street 2:
Mailing Address - City:FORT BENNING
Mailing Address - State:GA
Mailing Address - Zip Code:31905-5431
Mailing Address - Country:US
Mailing Address - Phone:706-626-1598
Mailing Address - Fax:
Practice Address - Street 1:6998 OLD CUSSETA RD
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-5431
Practice Address - Country:US
Practice Address - Phone:706-626-1598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-30
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other