Provider Demographics
NPI:1265781090
Name:BUSHMAN, JONATHAN P
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:P
Last Name:BUSHMAN
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 1:6 VICTORY DRIVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-1972
Mailing Address - Country:US
Mailing Address - Phone:816-883-2660
Mailing Address - Fax:816-792-9819
Practice Address - Street 1:1728 CLARKSON RD
Practice Address - Street 2:SUITE D
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-4976
Practice Address - Country:US
Practice Address - Phone:314-821-8258
Practice Address - Fax:314-821-3476
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007028938237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist