Basic Information
| Provider Information | |||||||||
| NPI: | 1265781090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSHMAN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | P | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 VICTORY DRIVE | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640681972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168832660 | ||||||||
| FaxNumber: | 8167929819 | ||||||||
| Practice Location | |||||||||
| Address1: | 1728 CLARKSON RD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630174976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148218258 | ||||||||
| FaxNumber: | 3148213476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2012 | ||||||||
| LastUpdateDate: | 03/19/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 2007028938 | MO | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.