Provider Demographics
NPI:1356759310
Name:HEYDRICK, JONATHAN (ATC, LAT)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:HEYDRICK
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 WESTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-8737
Mailing Address - Country:US
Mailing Address - Phone:214-552-8690
Mailing Address - Fax:
Practice Address - Street 1:3030 WATERVIEW PKWY
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-1400
Practice Address - Country:US
Practice Address - Phone:972-669-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT58712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer