Provider Demographics
NPI:1013352764
Name:NAGEM, JONATHON MICHAEL (PHD, MAT)
Entity Type:Individual
Prefix:DR
First Name:JONATHON
Middle Name:MICHAEL
Last Name:NAGEM
Suffix:
Gender:M
Credentials:PHD, MAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3821 PLACID LN
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-6773
Mailing Address - Country:US
Mailing Address - Phone:337-540-4144
Mailing Address - Fax:
Practice Address - Street 1:3821 PLACID LN
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-6773
Practice Address - Country:US
Practice Address - Phone:337-540-4144
Practice Address - Fax:337-205-5971
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA000793332B00000X
LADEN4679968225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
97176OtherBLUE CROSS BLUE SHIELD OF LOUISIANA