Provider Demographics
NPI:1679535256
Name:GRANT, JON (AT,C)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:
Last Name:GRANT
Suffix:
Gender:M
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12160 LONGSTRAW DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-8263
Mailing Address - Country:US
Mailing Address - Phone:317-826-0643
Mailing Address - Fax:
Practice Address - Street 1:8227 NORTHWEST BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1387
Practice Address - Country:US
Practice Address - Phone:317-415-5747
Practice Address - Fax:317-415-5748
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000235A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer