Provider Demographics
NPI:1194269423
Name:WOOLARD, JONATHAN LEE (LMBT)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:LEE
Last Name:WOOLARD
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6403 HIDDEN LAKE LOOP
Mailing Address - Street 2:18
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-2878
Mailing Address - Country:US
Mailing Address - Phone:910-527-9175
Mailing Address - Fax:
Practice Address - Street 1:3035 BOONE TRAIL EXT STE A
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3860
Practice Address - Country:US
Practice Address - Phone:910-920-1165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13933225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist