Provider Demographics
NPI:1316057060
Name:GREENE, JONATHAN E (PT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:E
Last Name:GREENE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:JONATHAN
Other - Middle Name:
Other - Last Name:GREENE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 29870
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9870
Mailing Address - Country:US
Mailing Address - Phone:602-772-3800
Mailing Address - Fax:602-772-3801
Practice Address - Street 1:10450 W MCDOWELL RD
Practice Address - Street 2:STE 102
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-4901
Practice Address - Country:US
Practice Address - Phone:623-846-7614
Practice Address - Fax:623-846-0993
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7236225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ7236OtherLICENSE #
AZ107079Medicaid
AZ107079Medicaid
AZ119760Medicare PIN