Provider Demographics
NPI:1962023309
Name:DAVIS, JOHNATHAN
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:DAVIS
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 1:252 W BROOKLYN AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-3024
Mailing Address - Country:US
Mailing Address - Phone:801-363-9400
Mailing Address - Fax:
Practice Address - Street 1:252 W BROOKLYN AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-3024
Practice Address - Country:US
Practice Address - Phone:801-363-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker