Provider Demographics
NPI:1487913208
Name:WEINER, JONATHAN I (LAC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:I
Last Name:WEINER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 ONEAL PKWY
Mailing Address - Street 2:#V11
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1420
Mailing Address - Country:US
Mailing Address - Phone:917-829-0220
Mailing Address - Fax:
Practice Address - Street 1:3035 ONEAL PKWY
Practice Address - Street 2:#V11
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1420
Practice Address - Country:US
Practice Address - Phone:917-829-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1778171100000X
NY003508171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist