Provider Demographics
NPI:1366796112
Name:EBERSOLE, JONATHAN A (PT, DPT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:A
Last Name:EBERSOLE
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 1:771 PILOT HOUSE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-1990
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:4831 S LABURNUM AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23231-2713
Practice Address - Country:US
Practice Address - Phone:804-222-0745
Practice Address - Fax:804-222-0748
Is Sole Proprietor?:No
Enumeration Date:2012-11-01
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305207689225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherGROUP MEDICARE PTAN
VAQ41989AOtherMEDICARE PTAN
VA1366796112OtherMEDICAID QMB