Provider Demographics
NPI:1033891585
Name:KINGSLEY, JONATHAN (OD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:KINGSLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PARK PL
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2994
Mailing Address - Country:US
Mailing Address - Phone:618-233-3040
Mailing Address - Fax:618-233-3739
Practice Address - Street 1:1 PARK PL
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2994
Practice Address - Country:US
Practice Address - Phone:618-233-3040
Practice Address - Fax:618-233-3739
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011741152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist