Provider Demographics
NPI:1235436031
Name:WISE, JONATHAN SOLOMON
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SOLOMON
Last Name:WISE
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 1:301 SULLIVAN PL APT 5K
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-2965
Mailing Address - Country:US
Mailing Address - Phone:646-942-7018
Mailing Address - Fax:
Practice Address - Street 1:360 CENTRAL AVE APT 228
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1695
Practice Address - Country:US
Practice Address - Phone:646-942-7018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-15
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020517235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist