Provider Demographics
NPI:1013594647
Name:CLEGG, JONATHAN (RN)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:CLEGG
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 SHEFFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-6803
Mailing Address - Country:US
Mailing Address - Phone:917-945-5795
Mailing Address - Fax:
Practice Address - Street 1:734 SHEFFIELD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-6803
Practice Address - Country:US
Practice Address - Phone:917-945-5795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY789523163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse