Provider Demographics
NPI:1326393190
Name:WIEZOREK, JONATHAN DWAIN (ATC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DWAIN
Last Name:WIEZOREK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 WILLOWS AVE
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62629-1717
Mailing Address - Country:US
Mailing Address - Phone:217-415-5806
Mailing Address - Fax:
Practice Address - Street 1:611 WILLOWS AVE
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:IL
Practice Address - Zip Code:62629-1717
Practice Address - Country:US
Practice Address - Phone:217-415-5806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960024472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer