Healthcare Provider Details

I. General information

NPI: 1336910777
Provider Name (Legal Business Name): JONATHAN KOJI HAMMOND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 01/15/2024
Certification Date: 01/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 E 7TH ST
BLOOMINGTON IN
47405-7109
US

IV. Provider business mailing address

7777 HIGHLAND PARK DR
BROWNSBURG IN
46112-7852
US

V. Phone/Fax

Practice location:
  • Phone: 812-856-2773
  • Fax:
Mailing address:
  • Phone: 317-966-2651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: