Healthcare Provider Details

I. General information

NPI: 1972362747
Provider Name (Legal Business Name): JONATHAN EVANS II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2024
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4641 FULTON DR NW
CANTON OH
44718-2384
US

IV. Provider business mailing address

4238 SHRINE PL NW
CANTON OH
44708-2829
US

V. Phone/Fax

Practice location:
  • Phone: 330-433-6075
  • Fax:
Mailing address:
  • Phone: 234-207-8656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: