Provider Demographics
NPI:1487084182
Name:GHAZAL, JONATHAN (ATC/L)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:GHAZAL
Suffix:
Gender:M
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3403 ANY WAY
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-1104
Mailing Address - Country:US
Mailing Address - Phone:503-339-5938
Mailing Address - Fax:
Practice Address - Street 1:3403 ANY WAY
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339
Practice Address - Country:US
Practice Address - Phone:503-339-5938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-15
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-AT-101545522255A2300X
TXAT70162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer