Provider Demographics
NPI:1063970291
Name:MATHIS, JON R
Entity type:Individual
Prefix:
First Name:JON
Middle Name:R
Last Name:MATHIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PROSPECT PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19076-1202
Mailing Address - Country:US
Mailing Address - Phone:610-657-2294
Mailing Address - Fax:
Practice Address - Street 1:661 13TH AVE
Practice Address - Street 2:
Practice Address - City:PROSPECT PARK
Practice Address - State:PA
Practice Address - Zip Code:19076-1202
Practice Address - Country:US
Practice Address - Phone:610-657-2294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer