Provider Demographics
NPI:1548953631
Name:SPROUSE, JONATHAN PATRICK
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:PATRICK
Last Name:SPROUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 E 450 N
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-3089
Mailing Address - Country:US
Mailing Address - Phone:435-671-7854
Mailing Address - Fax:
Practice Address - Street 1:190 S HIGHWAY 165
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9512
Practice Address - Country:US
Practice Address - Phone:435-755-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13286986-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist