Provider Demographics
NPI:1003341918
Name:WICKS, JONATHAN (ATC, LAT, MED)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:WICKS
Suffix:
Gender:M
Credentials:ATC, LAT, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2728 S ADAMS ST
Mailing Address - Street 2:UNIT 5
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3296
Mailing Address - Country:US
Mailing Address - Phone:574-250-9007
Mailing Address - Fax:
Practice Address - Street 1:1001 E 17TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-1590
Practice Address - Country:US
Practice Address - Phone:812-855-7920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002506A2084S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0010XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySports Medicine