Provider Demographics
NPI:1962511840
Name:GARDNER, JONATHAN TODD (CHES, PTA, EXP)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:TODD
Last Name:GARDNER
Suffix:
Gender:M
Credentials:CHES, PTA, EXP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 ROSELAND AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-4353
Mailing Address - Country:US
Mailing Address - Phone:269-966-1101
Mailing Address - Fax:269-966-1113
Practice Address - Street 1:2775 W DICKMAN RD
Practice Address - Street 2:SUITE L
Practice Address - City:SPRINGFIELD
Practice Address - State:MI
Practice Address - Zip Code:49015-4895
Practice Address - Country:US
Practice Address - Phone:269-966-1101
Practice Address - Fax:269-966-1113
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist