Provider Demographics
NPI:1194121731
Name:WASHINGTON, JON VINCENT
Entity type:Individual
Prefix:
First Name:JON
Middle Name:VINCENT
Last Name:WASHINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 RUFE SNOW DR
Mailing Address - Street 2:SUITE 404
Mailing Address - City:WATAUGA
Mailing Address - State:TX
Mailing Address - Zip Code:76148-2348
Mailing Address - Country:US
Mailing Address - Phone:817-514-6055
Mailing Address - Fax:
Practice Address - Street 1:6801 RUFE SNOW DR
Practice Address - Street 2:SUITE 404
Practice Address - City:WATAUGA
Practice Address - State:TX
Practice Address - Zip Code:76148-2348
Practice Address - Country:US
Practice Address - Phone:817-514-6055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist