Provider Demographics
NPI:1811096886
Name:WHITEHEAD, JON THOMAS
Entity type:Individual
Prefix:
First Name:JON
Middle Name:THOMAS
Last Name:WHITEHEAD
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 1:4144 LINDELL BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ST. LOIUS
Mailing Address - State:MO
Mailing Address - Zip Code:63108
Mailing Address - Country:US
Mailing Address - Phone:314-531-8224
Mailing Address - Fax:314-531-5683
Practice Address - Street 1:4144 LINDELL BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:ST. LOIUS
Practice Address - State:MO
Practice Address - Zip Code:63108
Practice Address - Country:US
Practice Address - Phone:314-531-8224
Practice Address - Fax:314-531-5683
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001533225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO5357960001Medicaid