1689764417 NPI number — JONATHAN SHERWOOD MSPT,ATC,MA,CSCS

Table of content: JONATHAN SHERWOOD MSPT,ATC,MA,CSCS (NPI 1689764417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689764417 NPI number — JONATHAN SHERWOOD MSPT,ATC,MA,CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHERWOOD
Provider First Name:
JONATHAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSPT,ATC,MA,CSCS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689764417
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2999 REGENT ST
Provider Second Line Business Mailing Address:
STE 225
Provider Business Mailing Address City Name:
BERKELEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94705-2190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-704-7760
Provider Business Mailing Address Fax Number:
510-704-7765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2999 REGENT ST
Provider Second Line Business Practice Location Address:
STE 225
Provider Business Practice Location Address City Name:
BERKELEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94705-2190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-704-7760
Provider Business Practice Location Address Fax Number:
510-704-7765
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  325055 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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