Provider Demographics
NPI:1518454743
Name:MAXON, JONIKA MARTIN
Entity Type:Individual
Prefix:
First Name:JONIKA
Middle Name:MARTIN
Last Name:MAXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16514 PROVENCE LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095-4982
Mailing Address - Country:US
Mailing Address - Phone:281-900-9078
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:281-900-9078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137142363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care