Provider Demographics
NPI:1740815786
Name:HIXSON, JONATHAN BENNETT (DPT)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BENNETT
Last Name:HIXSON
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 1:4160 PARK SOUTH STATION BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-4553
Mailing Address - Country:US
Mailing Address - Phone:336-543-3194
Mailing Address - Fax:
Practice Address - Street 1:4543 CHARLOTTE HWY STE 11
Practice Address - Street 2:
Practice Address - City:CLOVER
Practice Address - State:SC
Practice Address - Zip Code:29710-7057
Practice Address - Country:US
Practice Address - Phone:803-831-1454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10169225100000X
NCP19378225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist