Provider Demographics
NPI:1437747912
Name:TERRY, JOHNATHAN MAXWELL
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:MAXWELL
Last Name:TERRY
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 1:825 E 300 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2306
Mailing Address - Country:US
Mailing Address - Phone:385-485-9559
Mailing Address - Fax:
Practice Address - Street 1:825 E 300 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2306
Practice Address - Country:US
Practice Address - Phone:385-485-9559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator