Provider Demographics
NPI:1902502354
Name:COHEN, JONATHAN DAVID (PTA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:COHEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W ABRIENDO AVE APT 106C
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1158
Mailing Address - Country:US
Mailing Address - Phone:484-653-7780
Mailing Address - Fax:
Practice Address - Street 1:3525 E SPAULDING AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2208
Practice Address - Country:US
Practice Address - Phone:719-542-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0015034225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant