Provider Demographics
NPI:1205292257
Name:PACKER, JONATHAN REED (DPT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:REED
Last Name:PACKER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5629
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47716-5629
Mailing Address - Country:US
Mailing Address - Phone:812-759-7451
Mailing Address - Fax:812-759-7482
Practice Address - Street 1:165 NATCHEZ TRACE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7940
Practice Address - Country:US
Practice Address - Phone:270-796-4698
Practice Address - Fax:270-782-3274
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006771225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist