Provider Demographics
NPI:1023849759
Name:KUPIEC, JONATHAN WALTER (PT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:WALTER
Last Name:KUPIEC
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 DELAWARE AVE UNIT E
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6498
Mailing Address - Country:US
Mailing Address - Phone:720-204-4567
Mailing Address - Fax:
Practice Address - Street 1:701 DELAWARE AVE UNIT E
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6498
Practice Address - Country:US
Practice Address - Phone:720-204-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0020057225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist