Provider Demographics
NPI:1740015478
Name:ROMAN, JONATHAN J (PT, DPT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:J
Last Name:ROMAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 14TH ST APT 1/2
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1751
Mailing Address - Country:US
Mailing Address - Phone:908-773-1234
Mailing Address - Fax:
Practice Address - Street 1:1328 14TH ST APT 1/2
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1751
Practice Address - Country:US
Practice Address - Phone:908-773-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA306827225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist