Provider Demographics
NPI:1124243241
Name:AGEE, JONATHAN TODD (NP)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TODD
Last Name:AGEE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200E FAIRMAN AVE
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1644
Mailing Address - Country:US
Mailing Address - Phone:765-969-3678
Mailing Address - Fax:
Practice Address - Street 1:8320 MADISON AVE
Practice Address - Street 2:SUITE H
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-6066
Practice Address - Country:US
Practice Address - Phone:317-381-5252
Practice Address - Fax:317-859-5304
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000676A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200489910Medicaid
IN598030FMedicare Oscar/Certification
IN200489910Medicaid