Provider Demographics
NPI:1265288922
Name:HINES, JONATHAN TYLER (BS)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TYLER
Last Name:HINES
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 SUGAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WEAVERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28787-9665
Mailing Address - Country:US
Mailing Address - Phone:336-402-6710
Mailing Address - Fax:
Practice Address - Street 1:5203 MARYLAND WAY STE 104
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-5022
Practice Address - Country:US
Practice Address - Phone:615-560-6622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician