Provider Demographics
NPI:1154998540
Name:WHITE, JONATHAN TYLER (PA)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:TYLER
Last Name:WHITE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-2154
Mailing Address - Country:US
Mailing Address - Phone:423-784-8492
Mailing Address - Fax:423-784-8358
Practice Address - Street 1:402 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1238
Practice Address - Country:US
Practice Address - Phone:606-549-2656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-05
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5318363A00000X
KYPA2916363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5318OtherSTATE LICENSE
KYPA2916OtherKY MEDICAL LICENSE
KY7100770770Medicaid
KYTC120OtherMEDICAL LICENSE