Provider Demographics
NPI:1093060790
Name:WAKE, JONATHON
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:
Last Name:WAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 EXECUTIVE DR STE E
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5478
Mailing Address - Country:US
Mailing Address - Phone:317-689-7171
Mailing Address - Fax:317-315-2769
Practice Address - Street 1:40 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5479
Practice Address - Country:US
Practice Address - Phone:317-689-7171
Practice Address - Fax:317-315-2769
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501006597237700000X
IN17001321A237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist