Provider Demographics
NPI:1316755598
Name:EBERWINE, JONATHAN W
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:W
Last Name:EBERWINE
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 1:9152 HIGHWAY 278 NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-7010
Mailing Address - Country:US
Mailing Address - Phone:678-342-9339
Mailing Address - Fax:678-342-9319
Practice Address - Street 1:9152 HIGHWAY 278 NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-7010
Practice Address - Country:US
Practice Address - Phone:678-342-9339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACP025689A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant