| Doctor Name: | JONATHAN MICHAEL PROVOST |
| NPI Number: | 1619377751 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PT, DPT, CSCS |
| License Number: | 21309 |
| Business Practice Address: | 1 Towne Park Plz Norwich, CT - 063602247 |
| Business Phone Number: | 8608869111 |
| Business Fax Number: | |
| Mailing Address: | 1 Towne Park Plz, NORWICH |
| State: | CT |
| Postal Code: | 063602247 |
| Phone Number: | 8608869111 |
| Fax Number: | |
| NPI Enumeration Date: | 08/26/2014 |
| NPI Last Update Date: | 08/26/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225100000X |
| License Number: | 21309 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | MA |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) Physical therapists are health care professionals who evaluate and treat people with health problems resulting from injury or disease. PT |