Provider Demographics
NPI:1316244676
Name:WYATT, JOHNATHAN LYNN
Entity type:Individual
Prefix:MR
First Name:JOHNATHAN
Middle Name:LYNN
Last Name:WYATT
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 1:2609 FEATHERSTONE RD APT 133
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-2156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2609 FEATHERSTONE RD APT 133
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-2156
Practice Address - Country:US
Practice Address - Phone:806-570-2712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor