=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356979686
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN ERICSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2020
-----------------------------------------------------
Last Update Date | 01/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3901 RAINBOW BLVD # MS 4034
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66160-8500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-588-1908
-----------------------------------------------------
Fax | 913-588-8387
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1950 HARLEM AVE
-----------------------------------------------------
City | NORTH RIVERSIDE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60546-1470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-354-9250
-----------------------------------------------------
Fax | 708-354-8765
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036169823
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------