Provider Demographics
NPI:1447233754
Name:BAKER, JONATHAN GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:GLENN
Last Name:BAKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 14510
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-4510
Mailing Address - Country:US
Mailing Address - Phone:307-734-1800
Mailing Address - Fax:307-734-5012
Practice Address - Street 1:984 WEST BROADWAY
Practice Address - Street 2:SUITE 4
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-0000
Practice Address - Country:US
Practice Address - Phone:307-734-1800
Practice Address - Fax:307-734-5012
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WY8097A207N00000X
CAA55560207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology