Provider Demographics
NPI:1962105833
Name:MATTINGLY, JONATHAN ROBERT
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROBERT
Last Name:MATTINGLY
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 1:7805 BINFORD WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-5279
Mailing Address - Country:US
Mailing Address - Phone:502-489-4641
Mailing Address - Fax:
Practice Address - Street 1:500 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1702
Practice Address - Country:US
Practice Address - Phone:502-852-5193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-22
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program