Provider Demographics
NPI:1699245092
Name:WIMBERLEY, JONATHAN ISAAC (MAT, LAT, ATC)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:ISAAC
Last Name:WIMBERLEY
Suffix:
Gender:M
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16302 LOOP 493
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-7805
Mailing Address - Country:US
Mailing Address - Phone:806-863-7015
Mailing Address - Fax:
Practice Address - Street 1:16302 LOOP 493
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-7805
Practice Address - Country:US
Practice Address - Phone:806-863-7015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT38922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer