Provider Demographics
NPI:1245022516
Name:CARLSON, JONATHAN (PT, DPT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7790 COUNTY ROAD 2193 APT 39
Mailing Address - Street 2:
Mailing Address - City:WHITEHOUSE
Mailing Address - State:TX
Mailing Address - Zip Code:75791-9442
Mailing Address - Country:US
Mailing Address - Phone:720-402-1930
Mailing Address - Fax:
Practice Address - Street 1:4025 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8727
Practice Address - Country:US
Practice Address - Phone:903-561-2690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-21
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1406779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist