Individual
JONATHAN A EBERSOLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT, DPT
Contact information
Practice address
4831 S LABURNUM AVE, RICHMOND, VA 23231-2713
(804) 222-0745
(804) 222-0748
Mailing address
771 PILOT HOUSE DR, SUITE A, NEWPORT NEWS, VA 23606-1990
(757) 873-2302
(757) 873-2306
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
2305207689
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1366796112
MEDICAID QMB
VA
01
—
C05954
GROUP MEDICARE PTAN
VA
01
—
Q41989A
MEDICARE PTAN
VA
Enumeration date
11/01/2012
Last updated
03/13/2013
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