Provider Demographics
NPI:1336555895
Name:BENAVIDES, JONATHAN ALEXANDER (ATC)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:ALEXANDER
Last Name:BENAVIDES
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6506 LAZY WILLOW COURT
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412-4857
Mailing Address - Country:US
Mailing Address - Phone:361-236-9800
Mailing Address - Fax:
Practice Address - Street 1:6506 LAZY WILLOW COURT
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412-4857
Practice Address - Country:US
Practice Address - Phone:361-236-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-05
Last Update Date:2014-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20000176162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2000017616OtherATHLETIC TRAINER