Provider Demographics
NPI:1174023352
Name:KING, JONATHAN BRICE (NP)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BRICE
Last Name:KING
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 731912
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-1912
Mailing Address - Country:US
Mailing Address - Phone:903-877-7635
Mailing Address - Fax:903-877-7754
Practice Address - Street 1:721 CLINIC DR # A
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2043
Practice Address - Country:US
Practice Address - Phone:903-592-6152
Practice Address - Fax:903-592-5288
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136612363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily