Provider Demographics
NPI:1750882981
Name:WISMER, JONATHAN (PT, DPT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:WISMER
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 1:1302 SANDHILL DR
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-9550
Mailing Address - Country:US
Mailing Address - Phone:517-242-0425
Mailing Address - Fax:517-237-6089
Practice Address - Street 1:1302 SANDHILL DR
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:MI
Practice Address - Zip Code:48820-9550
Practice Address - Country:US
Practice Address - Phone:517-242-0425
Practice Address - Fax:517-237-6089
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018310225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1831195114Medicaid