Provider Demographics
NPI:1811925985
Name:ROYCE, JONATHAN M (PT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:ROYCE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 S HAM LN STE B
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3532
Mailing Address - Country:US
Mailing Address - Phone:209-490-5574
Mailing Address - Fax:209-222-6182
Practice Address - Street 1:631 S HAM LN STE B
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3532
Practice Address - Country:US
Practice Address - Phone:209-490-5574
Practice Address - Fax:209-222-6182
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT32533225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT325330Medicare ID - Type UnspecifiedMEDICARE NUMBER