Provider Demographics
NPI:1720810104
Name:RICHARDSON, JONATHAN NICHOLAS (OTR/L)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:NICHOLAS
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 SADDLE TREE DR
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:TN
Mailing Address - Zip Code:38343-6706
Mailing Address - Country:US
Mailing Address - Phone:731-439-6534
Mailing Address - Fax:
Practice Address - Street 1:2865 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-3070
Practice Address - Country:US
Practice Address - Phone:731-784-8405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8092225XG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XG0600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGerontology