Provider Demographics
NPI:1114520012
Name:HARRIS, JON ALLEN (DPT)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:ALLEN
Last Name:HARRIS
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 1:442 S MILLER ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-2625
Mailing Address - Country:US
Mailing Address - Phone:480-406-1947
Mailing Address - Fax:
Practice Address - Street 1:8679 E SAN ALBERTO
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4368
Practice Address - Country:US
Practice Address - Phone:480-447-3262
Practice Address - Fax:480-546-4121
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-21
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6480225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty