Provider Demographics
NPI:1053072090
Name:EVERETT, JONATHAN TIMOTHY
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TIMOTHY
Last Name:EVERETT
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 1:601 JOHN ST
Mailing Address - Street 2:BRONSON NEUROSCIENCE CENTER 1ST FLOOR
Mailing Address - City:GALESBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49053-7717
Mailing Address - Country:US
Mailing Address - Phone:269-266-2294
Mailing Address - Fax:
Practice Address - Street 1:601 JOHN ST STE M-124
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5377
Practice Address - Country:US
Practice Address - Phone:269-341-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704322588363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily