Healthcare Provider Details

I. General information

NPI: 1023668019
Provider Name (Legal Business Name): JONATHAN WILSON MAED, ATC, LAT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2019
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 UNION UNIVERSITY DR # 1811
JACKSON TN
38305-3656
US

IV. Provider business mailing address

1050 UNION UNIVERSITY DR # 1811
JACKSON TN
38305-3656
US

V. Phone/Fax

Practice location:
  • Phone: 731-661-5307
  • Fax:
Mailing address:
  • Phone: 731-661-5307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1999
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: