Provider Demographics
NPI:1366805467
Name:OTTO, JONATHAN CARL (DPT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:CARL
Last Name:OTTO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 E ARAPAHOE ST
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443-2402
Mailing Address - Country:US
Mailing Address - Phone:307-864-2146
Mailing Address - Fax:307-864-2857
Practice Address - Street 1:306 STONER LOOP
Practice Address - Street 2:SUITE 3
Practice Address - City:LAKESIDE
Practice Address - State:MT
Practice Address - Zip Code:59922-8600
Practice Address - Country:US
Practice Address - Phone:406-844-0744
Practice Address - Fax:406-844-0759
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11007225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist