Provider Demographics
NPI:1497292296
Name:BROWN, JOHNATHAN SR (ATC)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:BROWN
Suffix:SR
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 1:2110 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047-3721
Mailing Address - Country:US
Mailing Address - Phone:323-754-8641
Mailing Address - Fax:
Practice Address - Street 1:2110 W 95TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-3721
Practice Address - Country:US
Practice Address - Phone:323-754-8641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2000015128390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program