Healthcare Provider Details

I. General information

NPI: 1699393819
Provider Name (Legal Business Name): JON MICHAEL LINGLE ATP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 N NORTHEAST LOOP 323
TYLER TX
75708-2014
US

IV. Provider business mailing address

4709 STRATFORD DR
TYLER TX
75703-1535
US

V. Phone/Fax

Practice location:
  • Phone: 903-352-3788
  • Fax: 903-255-7830
Mailing address:
  • Phone: 903-216-5053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225CA2500X
TaxonomyAssistive Technology Supplier Rehabilitation Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: