Provider Demographics
NPI:1609135615
Name:WHITE, JONATHON W (DO)
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:W
Last Name:WHITE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62952-1104
Mailing Address - Country:US
Mailing Address - Phone:618-833-1691
Mailing Address - Fax:
Practice Address - Street 1:305 W JACKSON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-536-6621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125060525207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine