Provider Demographics
NPI:1740302025
Name:BURT, JONATHAN LYNDELL (LMT)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:LYNDELL
Last Name:BURT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20966 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-3937
Mailing Address - Country:US
Mailing Address - Phone:313-255-4070
Mailing Address - Fax:
Practice Address - Street 1:20966 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3937
Practice Address - Country:US
Practice Address - Phone:313-255-4070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBUS2002-01531174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist