Provider Demographics
NPI:1841023728
Name:STAMBAUGH, JONATHAN TYLAR (OTR)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TYLAR
Last Name:STAMBAUGH
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:781 HOWLAND HL
Mailing Address - Street 2:
Mailing Address - City:SOUTH SHORE
Mailing Address - State:KY
Mailing Address - Zip Code:41175-8510
Mailing Address - Country:US
Mailing Address - Phone:606-339-0575
Mailing Address - Fax:
Practice Address - Street 1:20 HOWARDS CREEK RD
Practice Address - Street 2:
Practice Address - City:SANDY HOOK
Practice Address - State:KY
Practice Address - Zip Code:41171-8535
Practice Address - Country:US
Practice Address - Phone:606-738-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY284733225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist