Provider Demographics
NPI:1992530349
Name:DEPORTER, JONATHON D (TLLP)
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:D
Last Name:DEPORTER
Suffix:
Gender:M
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2175 ROCK MERRIT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:28310-5000
Mailing Address - Country:US
Mailing Address - Phone:910-907-7698
Mailing Address - Fax:
Practice Address - Street 1:2175 ROCK MERRIT AVE
Practice Address - Street 2:
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-5000
Practice Address - Country:US
Practice Address - Phone:910-907-7698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program