Provider Demographics
NPI:1720430572
Name:WHITEHEAD, JONATHAN BRYN (NP)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BRYN
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:118 COLLEGE DRIVE BOX 5066
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39406
Mailing Address - Country:US
Mailing Address - Phone:601-266-5390
Mailing Address - Fax:601-266-4205
Practice Address - Street 1:2899 WEST 4TH STREET
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39406
Practice Address - Country:US
Practice Address - Phone:601-266-5370
Practice Address - Fax:601-266-4205
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901584363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily