Provider Demographics
NPI:1710734280
Name:MONTGOMERY, JONATHAN TAD (PT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TAD
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2269 NORTHWEST LOOP
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-1701
Mailing Address - Country:US
Mailing Address - Phone:254-965-2040
Mailing Address - Fax:254-965-7394
Practice Address - Street 1:220 WESTSIDE DR STE 300
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3868
Practice Address - Country:US
Practice Address - Phone:940-627-6290
Practice Address - Fax:940-290-0302
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1237933225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist