Provider Demographics
NPI:1245364017
Name:KONECNY, JONATHAN PETER (DC)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:PETER
Last Name:KONECNY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-1915
Mailing Address - Country:US
Mailing Address - Phone:203-334-4448
Mailing Address - Fax:203-333-1828
Practice Address - Street 1:2140 PARK AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-1915
Practice Address - Country:US
Practice Address - Phone:203-334-4448
Practice Address - Fax:203-333-1828
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000762111N00000X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT350000559Medicare ID - Type Unspecified
CTUO1596Medicare UPIN