Provider Demographics
NPI:1336632066
Name:GRAY, JON (PT)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:GRAY
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:PO BOX 2828
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912-2828
Mailing Address - Country:US
Mailing Address - Phone:406-926-2569
Mailing Address - Fax:
Practice Address - Street 1:116 GLACIER DR STE 102
Practice Address - Street 2:
Practice Address - City:LOLO
Practice Address - State:MT
Practice Address - Zip Code:59847-9343
Practice Address - Country:US
Practice Address - Phone:406-926-2569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-14991225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist