Provider Demographics
NPI:1104302298
Name:GARDNER, JONATHON WESLEY (PT, DPT, SCS, CSCS)
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:WESLEY
Last Name:GARDNER
Suffix:
Gender:
Credentials:PT, DPT, SCS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 PROVIDENCE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1251
Mailing Address - Country:US
Mailing Address - Phone:980-265-8869
Mailing Address - Fax:
Practice Address - Street 1:131 PROVIDENCE RD STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1251
Practice Address - Country:US
Practice Address - Phone:980-265-8869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC112882251S0007X
MD270172251X0800X
NCP233642251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic