Provider Demographics
NPI:1669008157
Name:ORTH, JONATHAN BRENT
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BRENT
Last Name:ORTH
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 1:5118 N 1350TH ST
Mailing Address - Street 2:
Mailing Address - City:WATSON
Mailing Address - State:IL
Mailing Address - Zip Code:62473-2271
Mailing Address - Country:US
Mailing Address - Phone:404-783-2146
Mailing Address - Fax:
Practice Address - Street 1:5118 N 1350TH ST
Practice Address - Street 2:
Practice Address - City:WATSON
Practice Address - State:IL
Practice Address - Zip Code:62473-2271
Practice Address - Country:US
Practice Address - Phone:404-783-2146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker