Provider Demographics
NPI:1356827349
Name:WHITE, JONATHAN STEVEN (ATC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:STEVEN
Last Name:WHITE
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 1:30 MAC ARTHUR DR
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-2338
Mailing Address - Country:US
Mailing Address - Phone:518-812-5238
Mailing Address - Fax:
Practice Address - Street 1:504 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31705-2796
Practice Address - Country:US
Practice Address - Phone:229-430-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0034242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAT003424OtherATHLETIC TRAINING