Provider Demographics
NPI:1750402442
Name:LEE, JONATHAN WADE (PT)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:WADE
Last Name:LEE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:JON
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4001 WAGON WHEEL RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-0137
Mailing Address - Country:US
Mailing Address - Phone:479-725-3043
Mailing Address - Fax:479-725-3098
Practice Address - Street 1:4001 WAGON WHEEL RD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-0137
Practice Address - Country:US
Practice Address - Phone:479-725-3043
Practice Address - Fax:479-725-3098
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1914225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPT1914OtherJON LEE