Provider Demographics
NPI:1164470068
Name:HENRY, JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:HENRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4572 SOUTH HAGADORN
Mailing Address - Street 2:2A EAST
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-5355
Mailing Address - Country:US
Mailing Address - Phone:517-349-8388
Mailing Address - Fax:517-349-1560
Practice Address - Street 1:4572 SOUTH HAGADORN
Practice Address - Street 2:2A EAST
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5355
Practice Address - Country:US
Practice Address - Phone:517-349-8388
Practice Address - Fax:517-349-1560
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046084208D00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101923850Medicaid
MI0334885Medicare PIN
MI0C36007053Medicare ID - Type UnspecifiedMEDICARE