Healthcare Provider Details

I. General information

NPI: 1154998540
Provider Name (Legal Business Name): JONATHAN TYLER WHITE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2021
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 CUMBERLAND AVE
WILLIAMSBURG KY
40769-1238
US

IV. Provider business mailing address

107 S MAIN ST
JELLICO TN
37762-2154
US

V. Phone/Fax

Practice location:
  • Phone: 606-549-2656
  • Fax:
Mailing address:
  • Phone: 423-784-8492
  • Fax: 423-784-8358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5318
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2916
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: