Provider Demographics
NPI:1225374366
Name:WHITE, JONATHAN ETHAN (COTA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ETHAN
Last Name:WHITE
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 EAST 163RD PLACE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473
Mailing Address - Country:US
Mailing Address - Phone:708-439-0654
Mailing Address - Fax:
Practice Address - Street 1:751 E 163RD PL
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2306
Practice Address - Country:US
Practice Address - Phone:708-439-0654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057003706224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant