Provider Demographics
NPI:1407376163
Name:WALL, JON COOPER JR (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:COOPER
Last Name:WALL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17580 INTERSTATE 45 S
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77384-4972
Mailing Address - Country:US
Mailing Address - Phone:936-267-5000
Mailing Address - Fax:
Practice Address - Street 1:17580 INTERSTATE 45 S
Practice Address - Street 2:
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384-4972
Practice Address - Country:US
Practice Address - Phone:936-267-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-23
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
TXU5836207XP3100X
TXBP10059625207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery