Provider Demographics
NPI:1972298941
Name:HUSTED, JONATHAN NATHANIEL
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:NATHANIEL
Last Name:HUSTED
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 1:244 BROOKFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-3446
Mailing Address - Country:US
Mailing Address - Phone:330-207-3426
Mailing Address - Fax:
Practice Address - Street 1:1527 GRANDIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-2305
Practice Address - Country:US
Practice Address - Phone:540-342-9525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-06
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10266225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant