Provider Demographics
NPI:1598735417
Name:CRISP, JONATHAN GENTRY (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:GENTRY
Last Name:CRISP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 BAGLEY CIR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-3126
Mailing Address - Country:US
Mailing Address - Phone:276-783-1226
Mailing Address - Fax:276-783-1425
Practice Address - Street 1:340 BAGLEY CIR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-3126
Practice Address - Country:US
Practice Address - Phone:276-783-1226
Practice Address - Fax:276-783-1425
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2008-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97002212084P0800X
VA01012395032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA89024YMedicaid
VA89024YMedicaid