Provider Demographics
NPI:1619553088
Name:COLEGROVE, JONATHAN TAYLOR
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TAYLOR
Last Name:COLEGROVE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4481 SUGAR MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45433-5536
Mailing Address - Country:US
Mailing Address - Phone:937-522-4784
Mailing Address - Fax:
Practice Address - Street 1:4481 SUGAR MAPLE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45433-5536
Practice Address - Country:US
Practice Address - Phone:937-522-4784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program