Provider Demographics
NPI:1710637947
Name:WYATT, JONATHAN HUNTER
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:HUNTER
Last Name:WYATT
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 1:1239 S TRENTON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-5420
Mailing Address - Country:US
Mailing Address - Phone:918-586-4245
Mailing Address - Fax:
Practice Address - Street 1:2548 E KENOSHA ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-6712
Practice Address - Country:US
Practice Address - Phone:918-355-0993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator