Provider Demographics
NPI:1528414240
Name:WOOD, JONATHAN (LMT)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:WOOD
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 S SAGINAW ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-2676
Mailing Address - Country:US
Mailing Address - Phone:810-893-6489
Mailing Address - Fax:
Practice Address - Street 1:512 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2516
Practice Address - Country:US
Practice Address - Phone:773-344-7708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501000547174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist