Provider Demographics
NPI:1811908411
Name:CONRAD, JONATHAN EDWIN (DPT)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:EDWIN
Last Name:CONRAD
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 1:775 E FM 1187
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036-4346
Mailing Address - Country:US
Mailing Address - Phone:817-297-9670
Mailing Address - Fax:817-297-9878
Practice Address - Street 1:775 E FM 1187
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:TX
Practice Address - Zip Code:76036-4346
Practice Address - Country:US
Practice Address - Phone:817-297-9670
Practice Address - Fax:817-297-9878
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11595792251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX189064201Medicaid