Provider Demographics
NPI:1114509643
Name:MCCONNELL, JONATHAN GREGG (STUDENT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:GREGG
Last Name:MCCONNELL
Suffix:
Gender:M
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 LIBERTY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35242-7547
Mailing Address - Country:US
Mailing Address - Phone:205-532-1919
Mailing Address - Fax:
Practice Address - Street 1:2105 E SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-2409
Practice Address - Country:US
Practice Address - Phone:334-288-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty