1366442543 NPI number — MR. JON FREDERICK WEAVER MA,CCC-A

Table of content: MR. JON FREDERICK WEAVER MA,CCC-A (NPI 1366442543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366442543 NPI number — MR. JON FREDERICK WEAVER MA,CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEAVER
Provider First Name:
JON
Provider Middle Name:
FREDERICK
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA,CCC-A
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366442543
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1542 S DIXON RD #F
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KOKOMO
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46902-7320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-457-4261
Provider Business Mailing Address Fax Number:
765-452-7655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1542S DIXON RD F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KOKOMO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46902-7320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-457-4261
Provider Business Practice Location Address Fax Number:
754-455-2577
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  23001956A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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