Provider Demographics
NPI:1780802405
Name:OWENS, JONATHAN MARK (OT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MARK
Last Name:OWENS
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:JON
Other - Middle Name:
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OT
Mailing Address - Street 1:1460 LIGHTHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:BLUFF DALE
Mailing Address - State:TX
Mailing Address - Zip Code:76433-4227
Mailing Address - Country:US
Mailing Address - Phone:817-269-9138
Mailing Address - Fax:
Practice Address - Street 1:1460 LIGHTHOUSE DR
Practice Address - Street 2:
Practice Address - City:BLUFF DALE
Practice Address - State:TX
Practice Address - Zip Code:76433-4227
Practice Address - Country:US
Practice Address - Phone:817-269-9138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110424225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Not Answered225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics