Provider Demographics
NPI:1063730570
Name:DAVENPORT, JONATHAN ACOB (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ACOB
Last Name:DAVENPORT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 SUMMITVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2715
Mailing Address - Country:US
Mailing Address - Phone:509-248-7949
Mailing Address - Fax:509-248-8291
Practice Address - Street 1:616 RAILROAD AVE
Practice Address - Street 2:STE 1&2
Practice Address - City:ZILLAH
Practice Address - State:WA
Practice Address - Zip Code:98953
Practice Address - Country:US
Practice Address - Phone:509-972-1190
Practice Address - Fax:509-249-4458
Is Sole Proprietor?:No
Enumeration Date:2010-05-07
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60297882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine