Provider Demographics
NPI:1578764387
Name:WALL, JONATHAN ROBERT
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROBERT
Last Name:WALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JON
Other - Middle Name:ROBERT
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:2940 S FRONTENAC ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-3790
Mailing Address - Country:US
Mailing Address - Phone:206-723-1381
Mailing Address - Fax:
Practice Address - Street 1:12811 SE 38TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-1326
Practice Address - Country:US
Practice Address - Phone:425-378-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015057174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist