Provider Demographics
NPI:1417322439
Name:THOMAS, JONATHAN HEATH (PT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:HEATH
Last Name:THOMAS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 30594
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28230-0594
Mailing Address - Country:US
Mailing Address - Phone:601-987-8200
Mailing Address - Fax:
Practice Address - Street 1:104 BURNEY DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6621
Practice Address - Country:US
Practice Address - Phone:601-987-8200
Practice Address - Fax:601-987-8211
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2710225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01771271Medicaid