Provider Demographics
NPI:1013260439
Name:CHENNAULT, JONATHAN L (MOT)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:L
Last Name:CHENNAULT
Suffix:
Gender:M
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1397 BROADVIEW AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-2845
Mailing Address - Country:US
Mailing Address - Phone:614-512-9879
Mailing Address - Fax:
Practice Address - Street 1:1397 BROADVIEW AVE
Practice Address - Street 2:APT 2
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-2845
Practice Address - Country:US
Practice Address - Phone:614-512-9879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT008106225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist