Provider Demographics
NPI:1790470987
Name:JONGA, ETHERTON T
Entity Type:Individual
Prefix:
First Name:ETHERTON
Middle Name:T
Last Name:JONGA
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 1:3001 HAMILTON CHURCH RD UNIT 443
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-7411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4422 3RD AVE.
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457
Practice Address - Country:US
Practice Address - Phone:718-960-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program