Provider Demographics
NPI:1396583902
Name:WEMPLE, JONATHAN RUSS
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RUSS
Last Name:WEMPLE
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 1:4010 INGRAHAM ST
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20781-1857
Mailing Address - Country:US
Mailing Address - Phone:301-291-1221
Mailing Address - Fax:
Practice Address - Street 1:11200 WAPLES MILL RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7407
Practice Address - Country:US
Practice Address - Phone:703-237-2219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician