Provider Demographics
NPI:1245988781
Name:REDDICK, JOHNATHAN BRETT (APRN, CNP)
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:BRETT
Last Name:REDDICK
Suffix:
Gender:M
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673
Mailing Address - Country:US
Mailing Address - Phone:262-251-7500
Mailing Address - Fax:
Practice Address - Street 1:1123 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1007
Practice Address - Country:US
Practice Address - Phone:336-832-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101031-875363L00000X
IL209023782363L00000X
NC5021066363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100250920Medicaid